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.,k�—,��'° STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
e � CountyO
A2Township Year
FOR DEDUCTION FROM ASSESSED VALUATION ,
3;a.:".t State Form 43709(R14/1-20)
e Prescribed by Department of Local Government FinancefzisIL .,
I
j 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. DEC 7 ZC Z
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
GIBSON COUNTY AUDITOR
Ap lic (owner or contract buyer-
Record number Page number
A6 -/& —b7 - 4, oL/_ oU3. 3o/^oL d : ,20 „2-D 56, 2 (I
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applica. e sole
assessment date,current year assessment date,current year date of a //'' legal. e.. able owner?
application5
60 e70O 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: the property in question:Annually Assessed
eal Property Annually Assessed
Mobile Home(IC 6-1.1-7)
Name o ortgagee contract seller <
Address of mortgagee or co racfseller(number and street,city,st te,and ZIP code) a\ ��Name of assignee or other owner or holder of mortgageT V1v
Drawer ISO
Address of assignee(number and street,city,state,and ZIP code) S-1.Q'(.---1
Card NO.
Does applicant own property in an If yes,what county? What Taxing District? Has this deduction
other county on property for
in Indiana? Yes o current year? L
❑ i tes U No
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 line 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 o County Auditor County Date(month,day,year)
I/We certify under the penalty of perjury that t / 2dforeing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned prope n date application is filed.
Signature(owner's full name) l/ Date(month,day,year)
Xi3,, �G. --- /Y.":
Full resident address of applicant(number and street,ci ,state,and ZIP code)
Person authorized by duly executed Power of Attorney 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 nenalties fnr nerinnr ran inrlurle imnncnnment'In to twn and a half veare and a fine not to OV,001.4 ein nnn