Mortgage_Martin (4)iai � 1 STATEMENT OF MORTGAGE OR CONTRACT INaEBTEDNESS
1\i' F FOR DEDUCTION FROM ASSESSED VALUATION
\' -�. / SlateForm43709 (R6/5-06) . . . . �
Presaibed by Depariment of Local Govemmem Finance
Coun Trnn�nship Year
I ���
NO
INSTRUCTIONS: � �e�%�O%
To be (led in person or by mail with the CountyAuditor of the county whe�e the property is loca[ed. �-y,,
Filing Dates: 1) Real P�operty: Dunng the 12 months before June Il o( the year the deduction is to be eliecti✓�'� .Q
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o(the ye�����.i��.eff�ctive.
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See �everse side for additional instructioQs and qualifrcations.
contiact
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Assessed value ot real property as of
M�ch t, wrrent year
Ho s on reverse side)
Key number / legal descr' lior
�
m - �tm . 9%
Mortgage / Contrad indebtedr
March 1, currenl year
If no, what is his / her exad share of interest?
If name on record is different than that of applicant,
of mortgagee or contrad seller
Addres6 of mortgagee or contract seller (number and
assignee or other owner or holder of mortgage
essignee (number and streef, city, state, ZIP
Does appficant own property in any other I If yes, what
county in Indiana?
approved in the amount of:
zo P I za�
Signature
Record number
Page number
as of Is the applicant the sole legal or equitabte
owner? ❑ Yes ❑ No +
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If wned with someone other lhan spouse, indicate with whom.
'-°�� Is the property in question:
❑ Mobife Horrie pC 61.1
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V�� To R�a � m q 2rzr� �
D3-���0
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zo zo zo
County Auditor
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been requested on
yeaR � Yes � No
20
certity under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
�ir (owners full name) Person authorized by duly executed Power of Attomey
�p,�/ }�/),� or by IC 6-1.1-12-.07
�ijt'f�siddnt address of applicant Address of authorized person
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