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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
y.?�'� FOR DEDUCTION FROM ASSESSED VALUATION •
-+s=-:?]State Form 43709(R13 1 10-15) �.
:„.,•-•
.' Prescribed by Department of Local Government Finance
INSTRUCTIONS:
To be filed in person or by mail. J i -�-
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. '' 1
Must be flied or posbnadced with the County Auditor or County Recorder of the county where the properly is II/ Court • cl ,
located on or before January 5 of the immediately succeeding calendar year. it er
2) Mobile/Manufactured Homes not assessed as Real Property.Must file with the County Auditor of the county ��
where the properly is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for add...dal instructions and qualifications.
Appacant . contract buyer- • reshicdons on reverse side) .
i 1SV H. �p 44_7( ) GIBBON COUNTY AUDITpR
T _ Key number I legal description ?�Jt,Pa/ Record number Page
to� 3 <3-9.07 oa/ ctrl 1 CO 5 3(0
Assessed veers of real property of Mortgage/Contract trdebtedness unpaid as of - Mortgage/Contract-indebtedness unpaid as of Is the app&rard the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
/2 5 OOd ❑ yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than cptv.ca,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
. Mme Home(IC 6-1.1-7)
Name of mortgagee ct seller
Address of mortgagee or contract seller(number and street,city, code)
Name of assignee or other owner or holder of mortgage '
Address of assignee(number and street,ay,state,and ZIP code) • . -
Does applicant own property in any 1 If yes.what county? - I what Taxing District? I Has tit deduction been requested if yes,slam amount of deduction
nil ? ❑Yes 0 N ' f 1_ 7 ❑Yes ❑No
A person is not entitled to this deduct RW r C 1 0/� �(O or contract indebtedness that is recorded in the county
recorder's office(including any home `^'�U� `-"r/ � Ice)that is the basis for the deduction.
Deduction approved in the amount of "� ,, // zz /
20 20 11.0 -61/5 CO 20
Signature of County Auden( 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!contract buyer of the aforementioned property on date application is filed.
Signature(owner's full name) Date(month,day.year)
Full resident address of applicant(number and street city,state,and ZIP code)
Person authorized by duly executed Power of Attomey or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,cly,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.
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