Mortgage_Scott r
STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS FT T. con i Year
LiiFOR DEDUCTION FROM ASSESSED VALUATION
State Farm 43709(R17 16-09)
Prescribed by Deparunent of local Government Finance '
File nM�anrk
INSTRUCTIONS: SEP :FSm�dd1�"�tk
To 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 Properly:Must file during the year for which the deduction is sought. , Co Auditor
ynh
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)coon _. ow ; County Recorder
before March 31 of each year(ha deductions sought. GIBBON COLNTV ,Cou County
See reverse side for additional instructions and qualifications.
Appfimnlfpwner or contract bux-see n 4 reverse side) / _
Taxing DistriG!/%•c�•`/�, number d`esescnp_(7(tion�.�'t`/q /�,J'w••-�7'/' Record number Page number
A • , ti a - - r4 - /9 - do3- Dot. ass"- o1-L aoiV 3/ a y
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of IS the applicant the so%
Mande 1:anent year Mardi 1,current year date of application legal or equitable owner?
/70 00 O' ❑ Yes ❑ No
If mined no,what is his/her exact share of interest? I If 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
Mobile Home(IC 6-1.1-7)
Name of mortgaggeee� nooar seller
/ F � t d iQI
Address of mortgagee or contract seller(number end street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assign`(number acrd sbee4 ern:state,and ZIP code) /�
7 9�� Drawer NO..67075/ ...
Does applicant own property in any other If yes,what county? • What Taring DNdr
enemy in Indiana? .
m
❑ Yes ❑ No .: // _
Card NO. ..L..J•/� ` _
COUNTYAUDITOR •"••• —
Deduction approved in the amount of: • . - -
20 20 20 20 20_ 20 20
Signature of County AAudittt000'r, • County Date(north,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 aforementi•ned property on date application is filed. .
Date(month,day,year)
elie. _ 1/le • I / Ya r
'/al address 9 St(nay/7 a stale, %U 4/76V,
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,end ZIP code)