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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
4d ., FOR DEDUCTION FROM ASSESSED VALUATION rcam�/
a* L State Form 43709(R14/1-20) JOB L—�
o 's Prescribed by Department of Local Government Finance GL
File Mark
INSTRUCTIONS: To be filed in person or by mail. sled
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 isCounty 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(o or contr ct
n buyer-see r ri Lions o reverse side)
A \ Record number Page nu ber
Taxing Di t Key number/legal descriptio
gZ _ 26-Z3- 16=100 - OUI ��7-02�� . 22— 5�� -
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is s tal e a plicaablehe e sole
assessment date,current year assessment date,current year date f a lic 'qn f 9 q
I (\�� Yes ❑No
If no,what is his/her exact share of interest? If owned wi someone other than spouse,indicate with whom
th property in question:Annually Assessed
FILEJ
If name on record is different than that of applicant,indicate below: -eel Property ❑Annually Assessed
`) Mobile Home 6-1.1-7)
Name of mortgagee or opntraeMeller A 1
Address of n' 'code) DEC 2 0 2022
Name of assi D enter NO �G
I
a..r- >4)
Address of at S7, 4°1 L GIBSON COUNTY AUDITOR
Card NO.
:ing District? Has this deductio en requested If yes,state amount of deduction
Does applicai f
other county ❑Yes ❑No I I on propertyor
current year'? Yes ❑No
in Indiana?
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or on ract 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)th t is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
)c /'G/ County Date(month, a ,Y.
=igna r- .f Co Auditor ar
c�� t Z�� 1`� 2
/ ✓- J YYY���-L
/We certify nder the pen y of perjury at the above and foregoing information is tru ar d correct and that the applicant is a esiden of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Dat)lh,day,y r)
Signature(ow rs full_ ZQ 2D Z 2
Full rest ent address pplica umbe�end street,c state,a�ZIP code)
2 E ve S Q r✓t t J" or)
Date(month,day,year)
Person authorized by duly executes{oo erb(Attorn)y or by 6-1.1-12-0.7
Address of authorized person (number and street,city,state,and ZIP code)
. _ _.___.__,...,..,....,...-,,.,n-iant,,r,to two and a half veers and a fine not to exceed$10,000.