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�bi �� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
's'��= FOR DEDUCTION FROM ASSESSED VALUATION � W �P Year
�.�1+ State Fwm 43709 (R6 / 5-06) - � �� i
Presaibed by Department of Local Gwemment Finance
NOV
INSTRUCTIONS: � � vFil�e Mark
To be filed in person or by mail with the County Audito� o/ the counry where fhe propedy is located. � ,an�
Filing Dates: 1) Real P�operty: Dunng the 12 months before June Il of the year the deductlon is to be efl��, A/t1DITOR
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2�f�e�a�a� educ6on is to be elfective.
See �everse side /o� additional inst�uctions and quali(ications. • �
Applicant (owner or c`onAtra-ct �buyer- see rictions on rever e side) � � .
/ �L !�I/v�
Tauing Distrid Key number / legal description Record number
� 7 '
� �+(O "oZ0'— -vo2 —�/0:3'D��.• page number
oo� -oo (0399
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year . March 1, current year owneR ❑ Yes ❑ No
3 o,�UOo �-
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that oi appiicant, indicate below: Is the property in question:
. . - . — - —:61.1-�
me of moAgagee or contrad seller
��/�-�� Dra���er NOA�. �••�°••3 p•�
Address of mortgagee or contrad selier (number and street; cify, state, ZIP
: � .. . ,
� Card NO . .......::.:...:......
Name of assignee or other owner or holder of mortgage �,_
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any olher If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current yea(J � Yes � No
COUNTY AUDITOR -
Deduction approved in the amounl of:
20 _Q� 20 �9_ 20 . 20 20 20 20
P ' � ����1
Signature County Auditor Date
' We certify under the penalty of perjury that the above and foregoing information is true and corred and lhat the applicants was / were
, resident of I' na and owner of the aforementioned property on March 1, 20
Signa (ow rs full e Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Fu resident address of applicant Address of authorized person
sa �� s� c�as�.� � s-�: o. ��o