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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
,, FOR DEDUCTION FROM ASSESSED VALUATION
6;y State Form 43709(R11/6-09) { T
Prescribed by Department of Local Government Finance (Y�I(I p.J D
INSTRUCTIONS: FdeE�laFIc - _ i �
To be filed in person or by mail Form tiled with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. @F east 1 Q1I 7 r
Must be filed with the County Auditor or County Recorder of the county where the property is located LLJT oG mm td
on or before January 5 of the immediately succeeding calendar year. County Recorder
2)Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the
county where the property is located during the twelve(12)months before March 31 of each year the
deduction is sought. GIBBON COUNTY AUDITOR
See reverse side for additional instructions and qualifications.
Ap (own o Iraa buyer-s resbict ns on reverse side)
a�` w Cr�a1 M IC�'1P.(� 1J• ►" j-
Taxirg Dis ' i(e number I legal description R num Page number
rn � -ro-36- lei-Coo.8sg-o�/� (3(/ Lakao � t.3-6113
Acsessed vat. real prope of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1. T t year March 1,current year date of application legal or equitable owner?
' p ��OQ 155 r� es 0 N
If no.what is hid/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant.indicate below I th rty in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of t D gage or contract Seller Wasters„'nJ r Sri c
Address)(ryo age rmnr setler(numbelands{tee[city.4ay..apd ZIP code) r
/meIII assignee ` j rlGx/gage yCkI& '1S �l 7I
Name of assgnee or other owner or holder gage
Address of assignee(number and street.aty,state,and ZIP code)
Does applicant own property in any other If yes,what county? What Taxing District? Has this deduction been requested on property
county Indiana? for current year?
ty in y❑ Yes No ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
•
Signature of County A'ditor / County Date(month.day,year)
I 1 We ce l nder (pena r)u �,F the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owne /Is /• 1 •/t r of t e • ed prope •• sate application is filed.
+.atur!1•v./P,/PO; t '(�� N. n Date(rtxntp�a,yoar) ��
Full re-dent atl re Hof appliant tuber a greet,ci(y:,slate.a `code!t c.76f)62.5.(M / �l/Gl,
(/9x131/9{1 �(•(}�//{1W,,,' S �J1lj t� 7Vaf 4/mar
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 I Date(nr. 'y,yea a O I3
Address of authorized person (number and street,city state,and ZIP code)
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