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g RAC, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
O ; .
..:' FOR DEDUCTION FROM ASSESSED VALUATION
m\:,. .�'. State Form 43709(R14/1-20) Gibson 2020
;;18•%• Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: To be filed in person or by mail.
Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. 0 County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is
located on or before January 5 of the calendar year in which the property taxes are first due and payable. ❑ County Recorder
See reverse :'.-for additional instructions and quaf tcations.
Applicant/ .r contract buyer-see restriction o reverse si )
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..%in tric Key nu eiml descr tion Recor number Pag umber
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contr ct indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of applicati no?
n�� legal or equitable owner?
❑Yes ❑No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is t property in question:Annually Assessed
Real Property \i.•• ally Assessed
; t.b• Ho a(IC 6-1.1-7)
Name of mortgagee or contract seller f rt� ' ,
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(r�ty,s a � .
Address of mortgagee or contract seller(number and stre t,city,state,and ZIP code) p'O
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Name of assignee or other.••:�L•" older. mortga 't� 0 2020
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Address of assignee(num.eranjreet,city,state,and ZIP code) SON G,Or
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of a'd drift ,R
other county on property for
in Indiana? ❑Yes ❑No current year? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person_'s_mne--�--—- he county
recorder's office(including any home equity line of credit that is recorded in the county !� tc5O. �'
COUNTY AUDIT dd�))
Deduction approved in the amount of: T i-1,}r C1 Q..O(•O•�'
20 20 20 20 JJ 17 ..
Card NO. ... . . ........
Signature ty Auditor .....itCounty I ...,�..r,year)
I/We certify under the penalty of perjury at 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.
gi nature owner's I name) Date(month,day,year)
M.
u I resident address of applicant(numbe and street,city state,and ZIP code
A .E. teak.(\ f 11 cam.an 4.-1 ,0AY
Person authorized by duly executed Power ofAttdrney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.