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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Court Township Year
- .1: FOR DEDUCTION FROM ASSESSED VALUATION ' �i
State Form 43709(R11/6-09)
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: JUN 1 IF? ,.•with:
M be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.
Filing Dates: 1) Real Pm petty:Must file during the year for which the deduction is sought. • County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property:Must Re during the twelve(12) i s
before March 31 of each year the deduction is sought 1 • jjtr711firA County Recorder
See reverse side for additional instructions and qualifications. GIBBON COON • • • -
Applicant curter or contract buyer-see r'rT�1ons(on reverse side)
•
Taxing District Key number/legal description Record number Page number
trade Sy .2 �0 .- i . fI - 301 - 000. 730, 007 ?-61?-61/S/, a37D
Assessed value of real as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,arrest year March 1,current year. 7 T date of application O Yes ❑ No
If no,what is his/her exact share of interest? 3 CJ It owned with someone other than spouse.indicate with whom
It name on record is different than that of applicant,indicate below Is the property in question:Annually Assessed
El Real Property El Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or con Iler N
Address of mortgagee or contract seller(number and street,City,stare.and ZIP code)
Name of assignee wother owner or holder of mortgage a{
Address of assignee(number and sheet,city,state,and ZIP code) •.•
Card )\r ..� �
Does applicant own property in any other If yes,what county? - What Tar o•
county in I diana? •
❑ No
❑ Yes r •
COUNTY AUDITOR
Deduction approved in the amount of.
•
20 20 20 20 20 20 20
Signature of unty Auditor c - County 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 applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
Signature(owner's ruff name) Date(month,day,year)
a.e� � Pn
�FUII resident address of appf 1(number(number aiF state,and ZIP code) /
5 f1-//�._ ti7L L o
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet,dty state,and ZIP code)