Mortgage_Layman (2) .� .•*E STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count
y ty Township Year
FOR-DEDUCTION-FROM ASSESSED VALUATION
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16
State Form 43709(R13/10-15) GIBSON 0 / jR
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Prescribed by Department of Local Government Finance (((���
INSTRUCTIONS: File Mark
To be filed in person or by mail. ,Fo ed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is County Auditor
located on of.before January'S of the immediately succeeding calendar year. - ❑ ounty Recorder
2) Mobile/Manufactured Homes not-assessed as Real Property:Must file with the County.Auditorofthe county
where the property is located during the twelve(12)months before March 31 of each year the deduction sought.
See reverse side for additional instructions and qualifications. - -
Applicant y/�'1,►�'nerorcontract yer-see r stri lionsso�nrevverseside)
—\l�.S�?ham I' 1 � Nuk
Taxing stri K n mber/legal description C Reco d num r PT number
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpa' as of Is the a pl- ant the sole
assessment date,current year assessment date,current year . <. date of a lic,.' v • - ' r� legal ore uitable owner?
4 001J—� Yes ElNo
If no,what is his/her exact share of interest? If:owned with som_one other t an/spouse,indicate with whom
If name on record is different than that of applicant,indicate below: /I the property in question:Annually Assessed
a Real Property ❑ Annually Assessed :,
_ Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller p��
n.
• lam \ ._
-. , . . ,,,
Address of mortgagee or contract seller( urn r and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage JUL ® LO20
4xso,41 5g_°' -
�1 ( „v AUDITOR .
�T O What Taxing District? G s )9'detfuidtio been requested If yes,state amount of deduction
Drawer 1\0 on'propertyfor . ,, • , .
current year? ❑Yes ❑No
�j s a balance on the persons mortgage or contract indebtedness that,is recorded in the county
r I�( J s recorded inthe county recorders office)that is the basis for the'deduction. `
Card d I�t O. -�-r . ,
`,, „ Q�j„ -0 cqr 0 COUNTYAUDITOR ..
20 I/ 20 20 20 ' 20 20
Signature of CountyAuditor . . County \! Date(month,day,year)
I/We certify under the penalty of perjury that the aEtt,Lp-
ngoing information is trued correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property onolication is filed.
ikSign (owner's II name) Date(month,day,year) �7
Full resident a ess of app' nt(num and street,city,state, d ZIP code)
Q I3 t5i- ) v ) P1-11 kY
Person authorized by duly cuted Power of Attorney or by IC Q-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code)