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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
v .. FOR DEDUCTION FROM ASSESSED VALUATION
' - ' State Form 43709(R11/6-09)
Prescribed by Department of Local Government Finance II • �•
I 't!a nt
INSTRUC71ONS: .
To be filed in person or by mad with the County Auditor or County Recorder of the county where the properly is located- Form iced m ut
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought &I (Qo4nt'/agdtor
2)Mobile/Manufactured Homes not assessed as Real Property.Must file during the twelve(12)months "rL'�J t U IJ
before March 31 of each year the deduction is sought - County Recorder
See reverse side for additional instructions and qualifications.
Ap�rer -con b r-see restrictions on rerersgside)_ —
Q�onsonreve GIBBON COUNTY AUDITOR
rug Key number/legal description Record number Page number
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s ae at, - l4 •bk- 36i - aa. 3(9 . na.R r)bI `� t\i
Assessed value Weal property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the appfi t the sole
March t:current year March t,wrtenl year date of aPPtgtion legal or equitable owner?
13 3_9` es ❑ No
If no,what Is his I her exact share of interest? If awned with someone other than spouse,indicate with whom
If name on record is ddferent than that of applicant,indicate below. tr �
Is the property in question:Annually Assessed
yea!Pmperty I:1 AnnuaRy Assessed
Mobde Home(IC 6-1.l-7)
of mortgagee or contract seller •
/n� ---
Address of mortgagee or con a der(number and steel,coy,state,and ZIP code) L�a))'�,`, �r --
Name of assignee or other owner or holder of mortgage Ward�r0 / O'
Address of assignee(number and sheet,city,state,and ZIP code) 1. fr�C•
Dces applicant own property in any other If yes,what county? • What Taxing Distictr ••�.. •Ply
county in Indiana? ❑ Yes 70 ❑ No
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/contract buyer of the aforementioned property on date application is filed. .
Signature(owner's fu0 name 1 Date(month,day,year)
ent address of appfia6lt(number and street,ray, te,and ZIP code)
/OW EC-5-1 i.j_4V 5--1-. yr: