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4. STATEMENT OF MORTGAGE OR CO B :� S County Township Year
s,f• FOR DEDUCTION FROM ASSESSED VA fYl/, g,J -
State Form 43709(Ri I/6-09)
Prescribed by Departmerd of Loral Government Finance
INSTRUCTIONS: MAR 31 2014 File Mark
To be filed in person or by mail with the County Auditor or County Recorder of the county where the ..•• is located. Form met with:
Filing Dates: 1) Real Property Must file during the year for which the deduction is s•••ht: __Ling; County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property M -t p: •. - ; . %i • {jf�)yhonths
before March 31 of each year the deduction is sought. UNT County Recorder
See reverse side for additional instructions and qualifications. GIBBON COU• NT
: 1(pa+Crwcontract b r-see re-striations reve�"rae.side)
Taxi,.O', `(�,1 des U Record number Page number
GizA9 Imp?) al-o5-`/0-1 SS 7- o03 71fto - o.Q 0701Y 54'S
Assessed value of real pwraoppe�Ryy as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contractindebtedness unpaid as of Is the apps t the sole
Mard11,anent year March 1!%a�ynent year date of app&ation legal or equitable owner?
aoncoo ❑ Yes 0 N
If no,what is his/her exact share of interest? ---tt owned with someone other than spouse,indicate with whom
If name on record is different than that of app&ant,indicate below: Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of/ogee or contract seller
K �LY �
Address of ee or contract seller(number and street,city,state,and ZIP code) — - - -
Name of assignee or other owner or holder of mortgage Drawer NO .P0/41
Address of assignee(number and street,cam:slate,and ZIP code)
Card NO. ....
Does applicant own property in any other If yes,what county? • What Taxing . .
county in Indiana? ❑ Yes
❑ No to
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor 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 contract buyer of the aforementioned property on date application is filed.
f Signatu (owners`uhf name) Date(month,day,year)
Foil nt address of a (nu
I? ar street.aTy,state,and ZIP code) Pr ZLa1 N. &ncLlnark � r.. ha cc6 I7I,3 . 1.17t7o
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city:state,and ZIP code) .