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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
r. FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R11/6-09)
Prescribed by Department of Local Government Femme tt; ' 1 1
Ilei �i. -
INSTRUCTIONS: - i
M be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. 1 F���.q c
Fling Dates: 1) Real Property:Must file during the year for which the deduction is sought. APR 1 O 4�J County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property.Must hie during the twelve(12)moo s LrJi
before March 31 of each year the deduction is sought - ��Recorder
See reverse side for additional instructions and qualifications.
nppr«ant(' b see resbFSasi re -`side) GIBBON COUNTY AUDITOR
�. . . Lae `!_,i so.. 3 — l
T..: .' ' 1 KeY T.- d Record number Page number•4'vakre of real property as of Mortgage/Contract indebtedness un as of Mortgage/mi:.rail indebtedness unpaid as of Is the
• Moit9a9 Pa apP&a beet n
Namh i year
74 1,current year date of application legal or equitable owner?
/S DO ❑ Yes 0 N
0 no,what Is his/her exact share of interest? If owned 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 ❑AnralNAd
Mobile Home QC 6-1.1-7)
Name of mortgagee or contrast seller
Address of mortgagee or contract setter(number and 4 city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any other If yes,what county? i What Taxing Disuict? Has this deduction been requested on property
county in Indiana? ❑ No for current year?❑ Yes ❑ Yes El No
COUNTY AUDITOR
Deduction approved in the amount at •
20 , n 20` /�y� ' 20 20 200 20 20 C
��rGo im' f , V' Caunry`r ,��'✓/�+�" ' _ Date(non{I� 1. IS
e certify under the penalty of perjury that the above and foregoing information Is true and correct and that the applicant is aarresident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signature(o - i r= :) d9 Date(month,day,year)
Si y -- /— / 5
resid• rA- ../.•rxant(number and street,city Zia,and ZIP code)
\j/�� rb ' it /sZb o <5 aa,(5,5-fad f Y,i . V76 .-S 9'C
Plrsan 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) .