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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Co{u�n Township Year
State fortn 43709 (RS / 4-03) � � � [y-..i
PresaiEea by Departmant of Local Gov?mment Finance �11
AUG 0 9 2006
INSTRUCTIONS: File Mark
To be filed in person or by mail with the CountyAuditor o)the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to`be eHe 1'rve.
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and Mua� tlh�2�ot yheiyeer{the`�dedpcfion is to be effective.
See reverse side (or additional instructions and qual�cations.
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Taxing
see
Assessed vatue of real property as of
March 1, curcent year
If �io, what is his / her exact
If name on record is diHerent
interest?
side)
Key number / I�gal description Record number
�G ao-�i ao�_c�o• 3sa-a�3 dCb �
Dao -c�3� - � Page number � a �
J
Mortgage / Contrad indebtedness unpaid as of Is the applican�g sole legal or
March 1, current year - owneR /(���Yes � No
BSC��
that of applicant,
of moAgagee or contract seller
Address of mortgagee or contrad seller (number and
Name of assignee or other owner or holder of mortgage
(numberand st2ef, city, state, ZIP
If owned with someone other than spouse, indicate with whom.
below:
city, state, ZIP
Does applicant own property in any olher I If yes. what county? What Taxin
county in Indiana?
20
Signature
COUNTY AUDITOR
approved in the amounl of:
20 �� 20 _ � 20 20
Q ��I� �
County Auditor
Is the property
❑ Moble Home QC 67.
Dra�ver \O.�.Q��D..:.`!:?�3
Card NO . .....................
on
ywpo��y w� w�roni yedrru resu No
20
Dafe
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We certify under the penalty of perjury that the above and foregoing information is lrue and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
(owners full
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address of applicant
Sev�i f'1 �, n i'.
Person authorized by duly executed Power of Atlomey
or by IC 6-1.1-12-.07
of authorized person