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�e���"� STATEMENT OF MORTGAGE OR CONTRACT INDESTEDNESS
's'� FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
�y• State Fortn 43709 (R6/ 5-06) . . - � ', �
��� Presaibed by DepaNnenl of Local Gwemmem Finance
INSTRUCTIONS: OCT 1 F��j(���
To be tiled in person o� by mail with the County Auditor of the county whe�e the property is located.
Filing Dates: 1) Real PropeRy: Dunng the 12 months before June Il o( the year the deduction is to be elfETjjqy ,�
2) Mobile Homes assessed under IC 6-1.1-7: Betweeri January 15 and March 2 0/ the year tiie d c1Con ��-�flective.
See reverse side /or additional instructions and qualiCcations. QIB80N CO NYY
Applicant ( wn r or contract buyer ee re tlons o reverse side)
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Ta�cing is d Key number / legal description Record number 6
�C.L� V �� � '�3 -�J(e — �Ud' � � /Y age number �
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of . Is lhe.applicant the sole legal or equitable
March 1, wtrent year Nlarch 1, curten year ownef? '❑ Yes ❑ No
�✓
If no, what is his / her, exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is diHerent ihan that of applicant, indicate below: Is lhe properiy in question:
❑ Real Properiy ❑ Mobile Hmie QC 61.1-�
�e of moAgagee or contrad selier ,
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Address af mor�qagee or contrad seller (number and street, , state, ZIP
Name ot aseignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code) �
Does applicant own property in any olher If yes, what counry? What Taxing Distrid? Has this dedudion been requested on
county in Indiana9 property for wrrent yeaR� Yes❑ No
COUNTY AUDITOR
Deduc6on approved in fhe amount of:
20 �� 20 �Q_ 20 20 20 20 20
P P
Signature County Auditor Date
�� We certify under lhe penalty of perjury that the above and foregoing information is true and correct and thal ihe applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners (ull name) Person authorized by duty executed Power oi Attomey
or by IC 6-1.1-12-.07
Fuli residenf address of applicant Address of authorized person