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i I ,_ IS,�. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS c �J�� itJ�r Year
FOR DEDUCTION FROM ASSESSED VALUATION
to"
State Form 43709(R11/6-09)
Presented by Department of Local Government Finance I I '
File Mark
INSIRUCl)ONS:
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: f) Real Property Must file during the year for which the deduction is sought GIBBON C OU 4fP/41'I r
2)Mobile/Manufactured Homes not assessed as Real Property Must Me during the twelve(12)coon s
before March 31 of each year the deductions sought ❑ County Recorder
-
See reverse side for additional instructions and qualifications.
Applicant Ser or contract buyer-see r1e`ssM�irionss on4\�����,,siinne) {r, `�r,�yr�`\
District
Hs r �� maker desaiplion J i ` C' Record number Page number
--C:0 (1-1,,. 1,3 -15rG "• (4DI Opt966( -erg d014 Salo
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract Indebtedness unpaid as of Is the applicant the sole
March 1;anet year March 1,�arrtpmt year date of application legal or equitable owner?
�LV[V[.3 Ypres ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom t
If name on record is ddfeent than that of applicant,Indicate below Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1A-7)
Name of gee or contract setter
Address mortgagee or contract seller(number and street,city,state,and ZIP cede)
Name of assignee or other owner or holder of mortgage �/ t�r� //�1�/l ) p� '� —
Address ofassgnee(number and street,city state,end ZIP code) -�u�� s ( bairn 1 J
'I(
Does applicant own property in any other If yes,what county? • WI
aunty in Indiana?
���///
co
❑ Yes Lj No _ L}C77o
COUNTY At ! — 544 70 \(
DeduNion approved in the amount of •
20 20 20 20 20_ 20 I 20
Signature of County Auditor 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/.. tract buyer of the- • -men'•red property on date application is filed.
lure 0,, - .,, - .:) Date(month,day.year)
F II - t,..• of a •l.: , -r rd street,dry,state,and ZIP.•%
Er /70
■••7 authorized by duty executed-• ,- of Attorney or• C 6-1.1- 2-03 Date(month,day year)
Address of authorized person (number and street,dry,state,and ZIP code)