Mortgage_Elpers (24) f�°z' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
tFOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R11/6-09)
Presaibed by Department of Loral Government Finance
He ark
INSTRUCTIONS:
To be filed in person or by mad with the County Auditor or County Recorder of the county where the property P
Y N h tY P perry is located.
Filing Dates: 1) Real e/Manufactured Must file during the year for which sought
is sought g ( ) A L.J 1 Coufly Aut,ditorw
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months CCOO6bu47+!()y F1'cord
before March 31 of each year the deduction is
See reverse side for additional instructions and qualifications. �/� ��
App (curer or contract buyer-see restrictions on reverse side) QA/(SF�,,y-1[
kr? qQ GIBBON COUNTY AUDITnR
Ta°�District Key number//lleggal d`eess`ariipt' Renard number Page number
°� orb. - 18- 3q- - `too -001, yy8— ot, y 2-012— 1073 /
value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as o Is the apps ant the sole
Mach 1,current year Mardi 1,arrtent year date of ap'pal:2t v legal or equitable aemer?
QO 000 ❑ Yes 0 No
If no,what is his/her exact share of interest? If owned with someone other thanrspouse,indicate with whom
If name on retold is different than that of applicant,indicate below Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
•S,B (w ,-4--0.-21—C S 4)
Address of mortgagee or contract suer(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage /�J { ' -� /n /, n
Add i assignee(number and sheet city,state,and ZIP code) / � t 025 / •O"m-
SE 3 `1 - 3 _�) f- ? .- 4-c 0673,A
Does applicant own property in any other If yes,what county? What Taxing DP
county in Indiana? ❑ Yes
❑ No
a01a- 6i31
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 20 20
Signau d County Data(month,day,year)
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.
Sig nire(Tiers/WI name. Date(month,day,year)
kc) tt a et
\/ Full resident address of a t number and street city:state,and ZIP code) _
f0141� Sash W FA l3rg0rL -TT--A-) Y7C9g
Person authorized by duly executed Power of Attorne or by IC 6-1.1-12-0.7 Date(month,day,War)
Address of authorized person (number and street city,state,and ZIP code) •