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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS ___ Count Township___ 1-ownship
Year
LY.i. .."., FOR DEDUCTION FROM ASSESSED VALUATION _ .......
State Form 43709(R14 I 1-20) Gibson 35)1/75(71 2020 i
•-:?..;--...._. ':•,..-' Prescribed by Department of Local Government Finance
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INSTRUCTIONS: To be filed in person or by mail.
Ef...3 County Auditor I
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. Li County Recorder
See reverse side for additional instructions and qualifications
.Apeiicent(o,nerO;contract buy,-- ‘,e restrictions on reverse side)
'aC)4kUC'''' ///li e,r5 I
Taxing District Key numbsXal description I Record number j Page num j. or l
:5-Ohn. )**/ - ial-3- -/0 I -00/, 6, C7/- 00?q.
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Assessed value o'real property as of Mortgage/Contract indebtedness unpa d Coor I Mortgage/Contract indebtedne55 unpaid as of Is the applicant taja-;-(31e i assessment date current year assessment date current year j date of application legal or equitable owner? j
60
' • 1 t3 56, )• iii Yes [ I No
If roYhat is ha I her exact share of interest? - If owajed wiM someone other than spouse indicate with whom __
1 I
1
If n27,'a onTe-cord is different than that of applicant.indicate bet°, Is the property'in question.Arin-i.TallyAssesse -
Rill-eel Property D Annually Assessed
Mobile Home(IC 6-1.1-7)
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Emj---eat-i- ortgagee or contract selie,NI8M ed Federat Cr ecie,f Lin.P h
AddIeSS of mortgagee oricontract sefler(hernhar and street,city state,and ZIP code) ------ I
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INanitOt.iissignee or other owner or hoIder of mortgage __ DEC 1 5 2D21
,i,,c ,--;-f assignee,(number and street.t s. 15' , 5to(9) '7 ," a.,fir-444,..)
.
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Does applicant own property in an It y, 8?C.12 I Jdtion been requeatIBSCI:NeCctLIPIPtion
'other county
in Indiana? Li Yes Likit<0_ji Drawer NO Pr E No
A person is not entitled to this deducti. . or contract indebtedness that is recorded in the county
recorder's office(including any home 'ice)that is the basis for the deduction
_ Card NO .
Deduction approved in the amount of
i
20 20
I 20 20 1 20_ _ 1 20 I
20
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Date(month day year)
Signature.of County Auditor it jatL__ _ ....ferr,- I County ,
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 I
owner/contract buyer of the aforementioned property on date application is filed. I
S g-,atu,e(orvcers ruff narne) ,Date(month day/year)
.1.--,..\.___,-,..---------
'-j-PtTresident araririeSSot applicant(cumber end Street c,:,,, state end ZIP code) ,
4-
Person aothorized by duly executed Power of Attorney or by IC 6-1_1-12-C 7 Date(month.day year) 1
1
Address of a(Ttitorized person (number and sfreet.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 S/0,000.