Mortgage_Ballard STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709(R13/10-15)
"-- Presabed by Department of Local Government Finance
INSTRUCTIONS: E
lii
To be filed in person or by malt Form filed with:
Filing Dates 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought D r 11 r
Must be filed or postmarked with the County Auditor or County Recorder of the county where the propel rs , aunty Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor ofthe�unty • County Recorder
where the property is located during the twelve(12)months before March 31 of eachyear the deduction e ;c. 'MI r
See reverse side for additional instructions and qualifications. GIBSON COUNTY Al Inlrrlp
` iru or iIt�iysnn �)ard
Tardily
s Ntns k f 26-� i z- Page number
T District Key number!legal description Record number
�tT 3 Soo-�n.5.3t��a� aolg 145719
Assessed value of real property as Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,oureid year date,current year date of application legal or equitable owner?Cyr 41/ 750 £fiery/ell tJ� e_ (,a-Yes 0 No
If no,what is his I her exact share of interest? If arced with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
. Real Property ❑ Annua lyAssessed
Mobile Home(IC 5-1.1-7)
Name of mortgagee or contract seller
e)lberFeJd Sfax. 6 — -
Address of mortgagee or contract seller(number and sheet city,state,and ZIP code) /� /�
Name of assignee or other comer or holder of...tog, I 1t�Q /'�r`
•
Address of assignee(number and street,city,state,and ZIP code) •
�� �'I�
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Does applicant awn property in any If yes,what county? What Taring District? Has this der � � 1- hAL,1r t
other county on property
in Indiana? ❑Yes ❑No current year, t J res Li No I
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity fine of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 ' 20' 20
Signature of County Auditor County - Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed. , , .
ignatur1V(o�w,n�e1rrs full name)
^-�!/,t- L1�\ l/AJ��t/'I1' Date(month,day,year)
bph
/tiz resi m address apprca4jXnumber and sheet,gib;state,and ZIP code)
("H&C( E 1 i o 3 !4n c h /dd4- -TM - y•7(03q
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 n Date(month,day,year)
Address of authorized person (number and street city,slate,and ZIP code)
The penalties for penury can include imprisonment up to two and a half years and a fine not to exceed$10,000. .