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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township gck Year
FOR DEDUCTION FROM ASSESSED VALUATION. State Form 43709(R14/1-20) !��n �A�O oC
Prescribed by Department of Local Government Finance
/- /
/ Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. la-County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ❑ County Recorder
located on or before January 5 of the calendar year in which the property taxes are first due and payable.
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
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Taxing District Key number/legal description Record numb Page number
Pa+o4, �(a-0�ag 300-00/. 108-6247 12l
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
/-?O, 0v0 Et ❑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: ILED
Is eal the party Propertyin question:❑AnnuallyAnnually AssessedAssessed
Name of mortgagee or contract seller
S,pr:ems \Jalb .-,'E- APR 2 2 20
Address of mortgagee or contr ct seller(number and street,city,state,and ZIP code)
�jl,, �� �/[�!� Drawer NOI Name of assignee or other owner or holder of mortgage %7/24€--AaLC. '"'- '- 1 /
GIBSON COUNTY Al
Address of assignee(number and street,city,state,and ZIP code) Card NO. G•
Does applicant own property in any If yes,what county? What Taxing District? Has this de
other county on property
in Indiana? ID Yes 10 current yea.. � - I
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or ntral4t 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 offic that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature C unty Auditor /i \j- County Date(month,day,year)
(a 't c/J(wnr�� ' l ,gor) `Il a a/a ,
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
owner/contract buyer of the aforementioned property on date application is filed.
Si natu a(owner's full name) Date(month,.day,year)
aE Sow ®y 'za ' 7r)Zz
ull resident address of licant(number and street,city,state,and ZIP code)
307g 3 1'75t ?cIncefton A/ f 7(0-70
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 penalties for oeriury can include imprisonment up to two and a half years and a fine not to exceed$10,000.