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. g., STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
11/4 ti
Prescribed by Department of Local Government Finance
INSTRUCTIONS: F IL t 1- j.
To be filed in person or by mad-
Rag Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought.
Must be tiled or postmarked with the County Auditor or County Recorder of the county where the prop( '1� .❑ County Auditor •
located on or before January 5 of the Immediately succeeding calendar year. I U t7 1. 0 2 i l
2) Mobile/Manufactured Homes not assessed as Real Property.Must file wdh the County Auditor of the county ❑ County Recorder
where the property is located during the twelve(12)months before Mardi 31 of each year the deductior is sought.
See reverse side for additional instructions and qualifications.
AppfinM(omier or -see resoi ' on reverse dde)j
GIBBON COUNTY C OUNTtY
Y AUDITOR
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Taxing District a ' `" OD al. 'LV %Dal 1;u7 mbe
- yz 7
Assessed value dread property as of Mortgage/Contract indebtedness unpaid as of - Mortgage/Contract indebtedness unpaid as of Is the app&rant the sole
assessment date and year assessnen data,aurora year date legal or equitable owner?
( ❑ Yes ❑ No
If n o,what is his/her exact share of interest? If owned someone other than spouse,indicate with whom
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It name on record is different than that of app&cant,indicate belay. Is the property to question:Annually Assessed
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 51
Address of mortgagee or contract setter(number and street,city,state,and ZIP code)
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Name of assignee or other owner or holder of mortgage
Address of assignee(masher and sheet,sky,state,and ZIP code)
Does app&cant own property in any It yes,what county? What Taxing District? Has this deduction been requested I If yes,state amount of deduction
other county ____I on property for I—I
inlndiana? ❑Yes 0 N - •�r_-nYes_❑No__
A person is not entitled to this deduction unless the person has a bah . - that is recorded in the county
recorder's office(rnduding any home egwiy fine of credit that is recce -..•' e deduction.
Deauaion approved in the amount ot: Drawer N O....a l...1.. .
20 20 20 Card NO. O`L- ` —�C i 20
Sg re of County Auditor e: 30 I n- roar CJ^ maNh.dal:Ye✓r)•
It We certify under the penalty of perjury that the above and foregoing information is true ana correct arm u car e ti appn.1t is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
fawners hdI name) Date(month,day,year)
8�,,,4 /ca:I.,y� c cG w.
resident address appli ant(number and street,dty,stale,and ZIP code)
Person authorized by duty executed Power ofAttorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,ray 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.