Mortgage_Robinson 4NE=T�! STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�; _�.T�� County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
' 022 2oto
"' '1' ,.'i State Form 43709(R14/1-20) �
_r T30.1). ;;; Prescribed by Department of Local Goveerrimeent,pFiri(a�nce `
CTI -. led " -- 2/6 Icy I • File"Mark
INSTRUCTIONS: To be filed in person orbymail
Form filed with:
)iling
Date: Form must be completed and dated in the calendar year for which the deduction is sought. County Auditor
Must be filed or postmarked with the CountyAuditor or County Recorder of the county where the property is
located on or before January 5 of the calendar year
�',,CJ�Jt11n1 eA 09)�30r1
Taxing District ey number/legal description Record number Page'rui be
11g•-OG-300-C1 0.4144—0 22 . j`l'°• `1 I
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the ap•licant the sole
assessment date,current year assessment date,current year date of ap is i legal ore stable owner?
Yes Ell No
If no,what is his/her exact share of interest? If owned with some a lithe.thk spouse,indicate with whom
If name on record is different than that of applicant,indicate below: s e property in question:Annually Assessed
Y
Mobile Home(IC 6-1.1-7)
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Name of mortga-aee�or contract seller ad
Address of morttaage(e or contracfseller number and street,city,state,and ZIP cocO)E C ED
320Z0 Real Property ['Annually Assessed
Name of assignee or other owner or,holder of mortgage .
Address of assignee(number and street,city,state,and ZIP code) GIBSON COUN1 Y AUDITOR
Does applicant own property in any ' If yes,what county? What Taxing District? Has this deductio een requested If yes,state•amount of deduction'
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 mortgage or on act 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)tha is the basis for the.deduction.
COUNTY AUDITOR '
Deduction approved in the amount of: a. '`
_20 1 0 20 20 20 20
Signature:of County Auditor II .I10/V- 'County 1� • • Date(mo h;" ar)
1/We certify under the penalty of perjury that the ab or ormation is rue nd correct and that the applicant i a re dent of Indiana and
n r/contract buyer a aforementioned property on date application is filed.
oignatu (owners f nam ��/��%%; C Date opt day ye ry
4...e
Fu` sid/�Ita�dddd ss of ' nt(number and city,st a and ZI code) t,
o � .
Person authorized by du y ex cuted Power of Attorney qby I 1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code)
r6a,,,,, tt;., r,^Prinry ran include imprisonment uo to two and a half years and a fine nr tn_PYrAed 4+^^^^ ,