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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
414- tfp FOR DEDUCTION FROM ASSESSED VALUATION State Form 43709(R14/1-20) Q /,C 17-2—
�' Prescribed by Department of Local Government Finance � � (((rrr vvv
File Mark
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. ( County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is //L�1\
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(ow er r contract/y`� buyerbu -seer coons o(nn reverse side)
� �'tv - r ` Record number a e numb
Taxing District Ke number/legal description r M Zer Pr
20-\y-1� -19�-000 T'� V It
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgag /Contract indebtedness unpaid as of Is the ap licant the sole
assessment date,current year assessment date,current year date o ppl ti ^ legal or !table owner?
V Yes ❑No
If no,what is his/her exact share of interest? If owned with s eone other han spouse,indicate with whom
If name on record is different than that of applicant,indicate below: I the property in question:Annually Assessed
Real Property 0 Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortg gee or contract el er ♦T LED
Ad(dd`wss\s of mortga ontract sel r(number and street,city,state,and ZIP code) F 1
Name of assignee or other owner or holder of mortgage
O C T 17 2022
Address of assignee(number and street,city,state,and ZIP code) ��
•
Does applicant own property in any If yes,what county? What Taxing Distri +./lzes ad r,� "•-Iequested If yes,state amount of deduction
other count GIBSON O kYtYf4tu IOR
IV
Indiana?y
❑Yes ❑No 'lTC1current year? Allik Tes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contr_ t 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 of County Auditor ,_/l\_k_.N�\ County k�\ 1 Date_(,rgor4h� r
p1 I CC�tIIJJ\\ -1 Z.
I/ ify under the penalty of perjury that t ve and foregoing information is true a d correct and that the applicant is a resid nt of Indiana and
w / ontract buyer of th forementioned property on date application is filed. r
Si ature owner's full n me) Date mo tt.. iay,year)
/X l(0 Fl "-)/-(322--
esident addre s of applicant(number and street,pity,state, nd Z c e)
erson authorized by duly executed Powys pf Attorney or by IC 6-1.1-12-0.7 • Date(month,day,year)
Address of authorized person (number and street,street,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$10,000.