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��A� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
�s• � FOR DEDUCTION FROM ASSESSED VALUATION C un Township Year
•. N� y' State Fwm 43709 (R6 / 5-06)
� Presaibed by Departmenl of local Gwemment Finance
JAN 0 4 2007
INSTRUCTIONS: File Mark
To be �led in person or by mail with the CountyAuditor ol the counfy where the property is located.
Fiiing Dates: 1J Real Property: During the 12 months be(ore ,lune Il of the year the deducUon is to be effecf �
2) Mobile Homes assessed under IC 6-L 1J: Between January 15 and March 2 0( the ye��l���`S��ctive.
See reverse side for additional instructions and qualifrcations.
Applicant
Taxing Distrid
contracf 6uyer -
Assessed value afrealproperry as of
March 1, curtent year
restrictlons on ^ +e) �
�
Key numC =5cription
a2(p-,2 2- O/ -20� -000,
� �� 7
MoAgage / Contrad indebtednes
March 1, c�rtent year
what is his / her exacl share of interesl?
If name on record is diHerent
mortgagee or contract
that
betow:
Record number
number
s unpaid as of Is the applicant the sole legal or equitable
owneR [� Yes ❑ No
/
If owned with someone other than spouse, indicate with whom.
Address of moRgagee or contract seller (number and stieet, ciry, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP
Does applicant own property in any other If yes, what wunty? 4Vhat Taxing Distrid?
county in Indiana?
� � � / .- U_ / / COUNTYAUDITOR � a 7
7
Deduction pproved in the amount of:
20
Signature
20 ��
1
20 � � 20 20
P
County Auditar
property in question:
al Property �❑ Modle Horrie (IC 61.1
Has this deduction been requesled on
property for curtent yea�? � Yes � No
20
Date
20
We certify under lhe penalty of perjury lhat the above and foregoing information is true and correct and that the applicants was ! were
resident of Indiana and owner of the aforementioned property on March 1, 20
a
Person authorized by duly exewted Power of Attomey
or by IC 6-1.1-12-.07
of aulhorized person