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�. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
' :mace371 FOR DEDUCTION FROM ASSESSED VALUATION
i` State Form 43709(R13/10-15) g ���'''-111 'g-�
Prescribed by Department of Local Government Finance tt
ode P 1 p '4
INSTRUCTIONS: - GTk ,
To be filed in person or by mail. Forme with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought Q t7 Q 1
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is unfy Auditor
located on or before January 5 of the immediatery succeeding calendar year.
2) Mobie/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county �❑ County Recorder
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought """'7�"xk
See reverse side for additional instructions and qualifications. GIBBON COUNTY AUDITOR
Applicant(owneror contract buyer-see resUEtions on reverse side) -
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Tam District Key number I legaldescription Record number Page number
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I art., Z6-f9-lg-3011-•OW. 978 020 20i8 45242
Assessed value of real pi„perty as of Mortgage/Contract indebtedn un aid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year ment date,current year date of application legal or equitable owner?
?aubsiaAl/ 4 agt-lk XYes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than spmrm,indicate with whom
If name on record is different than that of applicant indicate below-. Is pnq,rsty in question:Annually Assessed
Real Property 0 AnnualiyAsssessed
�/.� �7/(.�•, 1 Rn A {/� , Mobile Home(IC 6-1.1-7)
Name of mortgagee
f-A sfa_tt/ ✓J N-7 t 6ait_i__ -
Address of mortgagee or contract sever(number and street,dry,stte,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and sheet city.state,and ZIP code)
Does applicant own property in a 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 0 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
recorders office(including any home equity line of credit that is recorded in the county recorders office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 20 20
Signature of County Auditor 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.
ignal s rut n e) Date(month,day,ye
42-
7 / � of a�// umber street,say,state,and-zrP Full y/1ot'1r 1 .1-/I/ / 7 L/r
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet city slate,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.