Mortgage_Whitten n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
Af' li FOR DEDUCTION FROM ASSESSED VALUATION
rai' State Form 43709(R12/8-14) 2016
S--� •-� Department Prescribed by Deparent of Local Government Finance - T
INSTRUCTIONS:
To "(e rylark
be filed in person or by mail. Axal.
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is MA n Auditor
• located on or before January 5 of the immediately succeeding calendar year. R �] Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelve(12)•months before March 31 of each year the deduction is sough
.See reverse side for additional instructions and qualifications. _ tut
Applicant(owner or contract buyer-see restrictions on reverse side) GIBBON COUNTY AUDITOR
Heiley N. why t+ell
Taxing Distrait Key number/legal description Record numb?, Page r
26 - 18 -06 - 303 - 000.127 -02 2- i �r3
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year da of application legal or eq Isle owner?
*157, 625. 00 471 Yes ❑ No
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:Anhualy Assessed
' eat Property ❑ Annually Assessed
•Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
•
Ev gins ville Tecoct-letC )=e ciao, I Crecy } vlmain
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,city,state,and.ZIP_code).
Does applicant own property in a If yes,what cot been requested If yes,state amount of deduction
other county Drawer NO....-20..1.,�"
in Indiana? ❑yes '••• ]Yes ❑No
A person is not entitled to this deduction unless 'tract indebtedness that is recorded in the county
recorders office(including any home equity line 1 ll ` rat is the basis for the deduction.
N
Card O. L1 .J
Deduction approved in the amount of - f V W/ „
20_ 20_ 'LO I cu I c., 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 I contract buyer of the aforementioned property on date application is filed.
7S\b a. o'/4nners tuff name) tiA1`-'11,Inv1I` Date(month,day,year)
Full resident address tcant( umber and street city sp/a and ZIP code)
202. Rot ICRo� d OwenSv Ile, IN 41665
Person authorized by duty executed Power of Attomey or by IC 8-1.1-12-0.7 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. .