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r STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS county Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
-:- ?•' '- State Form 43709(R13/10-15) • .
Prescribed by Department of Local Government Finance FILED 9 File Mark
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To be filed in person or by mail. Form toed with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the d 7 („
Must be filed or postmarked with the County Auditor or County Recorder of the rHoperty is �• County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property.Must file with the C�tyAtrd' r o tmty County Recorder
where the property is located during the twelve(12)months before Mardi 31 of ea n is sought
See reverse side for additional instructions and qualifications.
Apptcant(o or seereslrtcyons on reverse side)_ GIBBON COUNTY AUDITOR
Taxing Dis ' Key number I legal description Record number Page number
l �/I� yze, Zto-i9-/9 -QUA oo / . 55 '9 6ac, I7 3o90
Assessed value of property as of Mortgage 1 Contract indebtedness unpaid as of • Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,axmnt year assessment date,anent year date of appr on legal or equitable owner?
/(oW95 /7 ❑ Yes ❑ No
If no,what is his/her exact sham of interest? If owned with someone other than spouse,indicate with whom
If name on record is afferent than that of applicant,indicate below. Is the property In question:Annually Assessed
rat Property ❑ Mobile Assesssed6-1.1-7)
Name of mortgagee or seller
Address of mortgagee or contract seder(numbeiand es6e t,city,state,and ZIP code) n. liCzt 611 ----
Name of assignee or other owner or holder of mortgage '
Address of assignee(number and street,thy,shot=,and ZIP code) -
i � - 3o� b —
Does applicant own property in any If yes,what county? - What Taxing District? Has th on prc
other in Indiana? ❑Yes ❑No - aauTent year? Ln ,co -_.
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 me analty .
recorder's office(includi g any home equriy fine of craft that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTYAUDITOR - -
Deduction approved in the amount of
20 20 20 20 20_ 20_ 20
Signatue of County Auden( County Date(month,day,yea) •
/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/co.... . -rot the afore •- A =• pro n date application is filed.
Signature I . Date(� y,year)
i,7 Fug --.._ . .:..J, of...- �. number. . city,state,and LP )
nn// ,�ll,J( u r Fes-ZIP lv 11'�Yr
Person autho du(y et icu Power of Attorney or by IC 6-1.1-120.7 Date(month,day.year)
Address of authorized person (number and street,ay,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.