Mortgage_Baumgart (4) •--., STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
- » ¢ FOR DEDUCTION FROM ASSESSED VALUATION
'4:41,-- E' State Form 43709(R12/6-14) •
Prescribed by Department of Local Government Finance _ i I ITITI.I
INSTRUCTIONS: i F I• .1 ,',i
To be fled in person or by mail. Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. MAY y PPnn Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is 1.W S!tY
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Aud for of the coun
where the property is located during the twelve(12)months before March 31 of each year the deduction is
See reverse side or additional instructions and qualifications. GIBBON Cn(jNTY q
11DIT
Applicant o r con tract buyer-see restrictions��iLaverse,sid OR
T. i•. trict ey number/legal description Record number Page b9
edi a e__ A-0l;-Og- /0O. OL0. oft Oo V 070/O /7%�p
'(vaIue of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Mt 1,current year March 1,Current year date of applica tio�0 /� legal or equitable owner?
62`) ❑ Yes ❑ No
i
If 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 property in question:Annually A scssad
Real Property ❑ Annually Assessed
Mobile Home(IC 6r1.1-7)
Name of mortgagee or contact seller
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,thy,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes ❑No current year? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's o.--.r..-'^......-.°^„•{.,,...o anthill Tina of rrru/it.that.is recorded in the county recorders office)that is the basis for the deduction.
)UNTY AUDITOR .
Deduction al /h gi Ce
Drawer NO 20_ . 20 20 20 20
Signature of Card :\r {1 O. (C ' `ter} LF County .
Date(month,day,year)
I I We certify under the penalty of perjury that me aoove miu iv.cy..,,ig 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.
1 Sig ^ (o��full name) Date(month,day,year)
I�^ re zYat.a4/
•} Full rFsi t address of applicant(number st , ty,state,an ZIP co/�e'/
1 0.o23 id . wiz ae , 6sK f,..r-6 l7 . ' (776019
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,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 510,000.