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4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'�' t FOR DEDUCTION FROM ASSESSED VALUATION t T h' Year
.��j • Siate Fortn 43709 (R6 / S-06) "
� � Resvibed by Depanment of Local Gwemment Finance
JUL 0 6 2007
INSTRUCTIONS: File Mark
To be frled in person or 6y mail with the County Audito� of the county where the p�operty is located. �7/ �
Filing Dates: i) Real Property: During !he 12 months before ,lune 17 0/ the year fhe deduction is to be elfecSve.� �
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o(the y�18�ro'�Lp�s4�i@�ORective.
See ieverse side for additional instnictions and qualifications.
Applicant (owner or contract
Taxing
see re rictions on reverse side) '/ //��n
� ey number / lega description _
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��o���
Assessed value of real property as of MoAgage / Contrect i
March 1, current year March 1, wrrent year
If no, what is his / her exact
If name on record is different than that of appticant,
of mortgagee ar contract :
of moRgagee �i�coniract seller (number and
Name of assignee or other owner or holder of mortgage
of assignee (number and street, city, state, ZIP
Record number
Page number
� VO J✓ � 1
ndebtedness unpaid as of Is the applicant he sole legal or equitable
� L� �00 owneR s ❑ No
�
If owned with someone other than spouse, indicate with whom.
city, state, ZIP
Dues applicant ovrn property in any other I If yes, what county?
county in Indiana?
Ueauction approvetl in the amount of:
zo P ( zo
Signature _
r�
What Taxing Distri
COUNTY AUDITOR
20 2� 2�
, ,3
County Auditor
property in question:
al Property ❑ Mobile Horrie pC 61.1-�
t
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' —���=n.requested on
DY:11YC1' 1��Q.�..S.— ✓ ��O Z
C:II'[� 1��0. ... ,
20
Date
20
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We certify under the penalty of perjury thai the above and foregoing information is true and corred and lhat ihe applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
C�J
fent address of applicanf / (/. ,f, �c�
v. �3�x33/ ��A��;s�� �
Person authorized by duly executed Power of Atlomey
or by IC 6-1.1-12-.07 �
Address of authorized person