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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
1:
FOR DEDUCTION FROM ASSESSED VALUATION
I' State Form 43709(R11/6-09)
Prescribed by Department of Local Government Finance I N j
File j• .rk
INSTRUCTIONS:
To be filed in person or by mail with the Court Auditor or Court Recorder of the county where the Fwtn Ned
Pe Y N N N property is located.
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. I N 0 M Z�1nty Auditor
2) Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months 1
before March 31 of each year the deduction is sought. - I County Recorder
See reverse sidei•-additional instructions and qualifications. a •X1.1.41
Appfiant(owner.7.7 ..••b r 'r-see 7 side I
• �(�4�I �o )) f�(I f a/] '�/� / GIBBON COUNTY AUDITOR I
Taxing District /1 f w� / I •�C.s M-, ct-JaV-OD I I Record miter Page S306
Assessed value of real property as of�/ Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of is the apprxant the sole
March 1,current year March 1, rtecnyyear date of appGption legal or equitable owner?
CP:Di
El Yes El No
If no,what is his/her exact share of interest? If owned with someone other than spv MP,Iindicate with whom
If name on record is different than that of appfcanL bid the property in question:Annually Assessed
1 `��(� (��/ I Real Property ❑Annually HAssessed
Name of mortgagee or contract seller
4eCk. `-^' I�\ `-^ I Motile Home(IC 6-1.1-7)
Address of mortgagee or contract seller(number and s /�( /�
I
Name of assignee or other owner or holder of mortgagr V-3 / J �v v Address of assignee(number and stree4 city,sate.an
Does appficani own popery in any other ,� s U'I deduction been requested on property
county in Indiana? ❑ yes ❑ No ._...,(-3 current years ❑ Yes
❑ No
Deduction approved in the amount of: .%:':•,•' I
? 'J�'• THOMSON REUTERS-
20 20 20 20
—
Signature of County Auditor County I Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the 2pplicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed. I
IDate(month,day,year)7X)
F ent address of appr�lwnt(number and street city,slate and ZIP code) I
!oc -(cs E /be,A�/1. 4> Gt3
P authorized by drily executed Power of Attorney or by IC 6-1.1-12-0.7 I Date(month,day,year)
Address of authorized person (number and street,city.state,and ZIP code) I