Mortgage_Anderson 1;s;: STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS s� . Year
.9!r --;; FOR DEDUCTION FROM ASSESSED VALUATION Fl L �;t
s' ' 111- State Form 43709(R11/6-09)
Prescribed by Department of Local Government Finance g
INSTRUCTIONS: APR 2 e711
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. Forms 3 -
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. d#-•l • my Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)mon •/'--.1I.
before March 31 of each year the deduction is sought. GIBSON CO JN 'Atf$4er
See reverse side for additional instructions and qualifications.
App owner or contract buyerstnrlbns gn rem side)
Taxing District x Key number/!w/legal description ,_ Record number Page number
217n c.‘w a& -IT-ai/o/ -aoo. a 7 7 -o � 3 a00 / 3 &3
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Marts t,current year March 1,current year date of application o owner?
legal or equitable owne
108 3/ ? ❑ Yes El No
If no,what Is his/her exact share of interest? If owned with someone othei than spnr.c,indicate with whom
__ _
If name on record is different than that of applicant,l d - - __ •Is the property in question:Annually Assessed
___ -- I_I Real Property ❑ArmtanyAssessed
Mobile Home QC 6-1.1-7)
Name at mortgagee or contract seller (�c ,� - ----
Address �` Ind l'U MOO
mortgagee or contract seller(number and
Name of assignee or other owner or holder of mangy 50 H
Adds s pissignee(number and street My,state, Let/t \(7. -
Dees applicant own• •:- in any o - Has this deduction been requested on property
county in Indiana? / ❑ Yes ❑ Nc )(1 I2 I for arrest year? -
OC� J //'I-� ❑ Yes ❑ No
Deduction approved in the amount of:--- 1 3(...0 )
20 20 J1 20 20
Signs rCOUnty Auditor / I �/ I I l•� .-
/b//``/`"_ Date(month,day Yeah
I/We certify under the penal. of perjt d that the applicant is a resident of Indiana and
_ owner I con.. • ye •f r r aforemer
k !gat ' I Date( r)
.,, 4/ `7!3
ent address of a..; t(number a • .:-t,city-state,and ZIP code)•
• •
ys S. lit`c t cr,'4 /Or.1- e / Po-r et'-7 - 4 i v '(7 `v.V
Person authorized by dtdy executed Power of Attorney or by IC 6-1,-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code) .