Mortgage_Simmons STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
FOR DEDUCTION FROM ASSESSED VALUATION
is State Form 43709(R11/6-09)
Prescribed by Department of Local Government Finance
I I FO ax
INSTRUCTIONS:
Form filed with:
To be filed in person or by mad with the CountyAuditor or County Recorder of the county where the properly is located. c1
Filing Dates: 1) Real Property-Must file during the year for which the deduction is sought. J U 2 t 2[ wily Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months
before March 31 of each year the deduction is sought - ❑ County Recorder•
See reverse side for additional instructions and qualifications. W i rin11;
Apprknt carer or contract buyer-see restrictions on verse side) ` GIBSUN COUNTY AUDITOR
7 District Key number/legal description Record number Page number
(62 — / 1 — 0 7 — )--o/-0001 .546—‘9J-8 0 31473
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appfirarl the sole
March 1,wrest year March 1,Oiliert q 3 , L date of application legal re Yes ❑ ON
If no,what is his/her exact share of interest? II If owned with someone other than spouse,Indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
f obde Home(IC 6-1.1-7)
Name of mortgagee or seller
•
Address of r ortgagee or suer(number and street city,stabs,and ZIP rode)
Name of assignee or other owner or holder of mortgage _ - _ _
Address of argsaeec city,state.and ZI I 1 `n`1 ao13-3�f l'
7r
!,(/ /3 Lv
Does applicant own property in any other If r ` n deduction been requested on property
county in Indiana? ❑ Yes ❑ No �, 1`^�Q"V��(�..7W�,,1,,�r-�� t n ❑ Yes ❑ No
Deducton approved N the amount of: ��"— V
20 20 20 20 20 20 20
Signature County Author _ `Jf. / t County Date(month,day,year)
I 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 I contrail buyer of the aforementioned property on date application is filed.
�Sigtra
rue me) A9'C!zi' Date(72 day,Year)
Full ' ent • mess of a t(number a 4 ,slate,and ZIP code)
0 F 71 • , in `f76, 70
authorized by duly executed of Attorney or by IC 6-1.1-12-0.7 7 Date(rnorah,day,year)
Address of authorized person (number and sheet,city,state,and ZIP code) _