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.+.-�=•� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS To s p Year
r,, ., FOR OEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R8 / 2f17) �
's'-' / Presaibea
by Departmeni of Loral Govemment Finance
de
INSTRUCTIONS:
To be filed in person or by mai7 wdh fhe CountyAuditor o/ the county where the�property is located. � `-yr, ��
F�7ing Dates: 7) Real Property: Dunng the 12 months belore June 11 of the }reai the deducfion is to be elfeclive. ���
2) Mobile Homes assessed under IC 6-7. 7-7: Behveen January 75 and March 2 0/ the year the dedur�i��l� t���6v6.A U DITOR
See reverse side (a additional insWCtions and qualifiwfions. OU TY
mnfrae buye. -
side)
i�ydrg Distria � Key number / leyal desaiplion � Record number Page num�
/, a�-. 3- _ oo-ooi. a�8-�o. �. .s� �
Pssessed value of mal propsry as d March 1, aarent year Mortgage I ConUacl iMeWedness unpaid as of March 1, Is the applinnt 1he sWa legal w equitade owneR
airteM yaar � O �
❑Yes ❑ No
�. what is his / her exad share of irrteresl? If amed wi�h someone dher Ihan spouse, indicate wi�h whom.
Name ot mortgagee or coni`aU si
Address of mortgagea w ��rac7
dty. sfate, entl ZIP coOe)
Name of assignee d oUrer o.vner or hdCer of mMgage
Address of assigrree (num6er arM sfreel, city, 3ate, antl Z/P code)
Does applicanl own property in enY other It yes, whffi counry?
counry in Indanal
❑Yes ❑ No
COU
Deductian approved in the amounl of:
20 n 9 20 20 20
of Counry Audi�nr
0
20
Is the ploperty in quesUon:
❑ Real PropeAy ❑ Mobile Home
1-� A��, A�r�,v i3 —
OPJ�-s9 ,�
20
20 _
I/ We cer�fy ur�r the penalry of perjury that'/fie above and toregoing intwmation is true and cortect and that the applinnts was / were a resident of
Indiana and od✓er of the aforemenfioned pL6perty on March 1, 20
SignaWr owne/slullname) l� � Date(mon(h.dey.yee�
� C1 �
•E�I�n�d���a � V J� Cdstree(�J�Fh-C�I l rT�'d e�
l C.��l.� �1�.s-�.0
Person authonzed by tluty exewled Pawer ot PAtomey w by IC E7.1-72.07 ' Date (monfh, day, yBa�
person (nomberantlsfreei.aty.stete.aMZIPCOOe)