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z.„ STATEMENT
FOR OF DEDUCTION MORTGAGEFROMASSESS OR CONTRACEDVALUATT INDEBTEDNESSION County Township Year
\, b `�2 Z
State Form 43709(R14/1-20)
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: To be filed in person or by mail.
Form file with:
Filing 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 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 side for additional instructions and qualifications.
Applicant�(vwger or contract�u a restrictio s on r e side)
Taxing D' ict/- K nu �/teggl des��lion�S —o O' �C\--0c1 /-' Rg�ord numbe{ Pa1ge�ber
Assessed valuel of real property as of Mortgage/Coon1\tract indebtedness unpaid as of Morttga e/Contract(indebtedness unpaid as`ooff be)__
the pli t the sole
assessment date,current year assessment date,current year date of p a n legal o eqable owner?
�� OOO _ Yes ❑No
If no,what is his/her exact share of interest? If owned with omeone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: e property in question:Annually Assessed
Real Property ❑Annually Assessed
Q1� Mobile Home(IC 6-1.1-7)
Nam f mortgage pr co ct se @r���� ��J��-
Addr ss of mortgagee or contract seller(number and street,city,state,and Zl, r//)/
Name of assignee v orh fitt. :e Drawer NO...l.:• ••
-I / ,
Address of assigne a street,city,state,and ZIP code) / 3
77� .2�2 Card NO.
Does applicant own property Q If�re ,what county? What Ta, e amount of deduction
other county
in Indiana? ❑Yes No
A person is not entitled to this dgdygCio/ .r..- r'/-.•erson has a balance on the person's mortgage or c n\act indebtedness that is recorded in the county
recorder's office(iffeJl fln iiiqu• A y . • credit that is recorded in the county recorder's office tha�f is the basis for the deduction.
fGtBSON GpU COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Audit ! . County Date( on day ear)
We certify under the penalty of perjury that the nd foregoing information is tr a net correct and that the applicant is rest ent of Indiana and
o ner/contract buyer of the aforementioned property on date application is filed.
VSig tture(owner's full na e.,..‘ Date(month,day,year)
//\\ ll rll r side o applicant(number a reet,city,state,and ZIP co e)
Person authorized by duly executed rower 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)
-•-- --..,.,.,,...r,,,<riury can include imprisonment up to two and a half years and a fine not to exceed$10.000.