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� e °� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'a' � FOR DEDUCTION FROM ASSESSED VALUATION Coun Tovmship Year
'-... . � State Form 43709 (R6 / SO6) �
� M Presaibed by Deparirrent of Lwal Gwemment Finance
INSTRUCTIONS: .IUN 2 �.�e0r�ar�
To be Filed in person or by mail with the CountyAuditor of fhe county where the p�opeRy is located. �� �
Filing Dates: 7) Real P�operty: Dunng lhe 12 months befoie ,lune 11 0( the year the deducfion is to be e/f�ct
2) Mobile Homes assessed under IC 6-7. 7-7: Between January 15 and March 2 of thg�p(m�t(o �d+� eBective.
See reverse srde for additional instructions and qualifrcations.
Applicant (ownerorconfract
Taxing Distrid
v"cUlv�ca
Assessed value of real
March 1, wrrent year
side)
Key number / tegal description I Record number ��
p a�-/a -�3-3a�a -0 Page number a� g3
as of MoAgage / Contred indebtedness unpaid as of Is the applicant the sole legal or equitable
March rent year owneR ❑ Yes � No
��O(J(J
Ii no, what is his / her exact share of interest?
name on
than that of appticanf, indicate below:
�me of mortgagee or conVad sellP�
%
Addresjm�' � a�� •
If owned with someone other lhan spouse, indicate with whom.
�d �freet, city. state, ZIP
- �,�,�,,°:�,`:a�q,3 ��;���
��t�,
, ���J`�p �v '
C.a� (�
DP �>'X- refiy If
U
cou� .a!
�
e
„ �tate, ZIP code)
any other � If yes, what county? � What Taxing Distrid?
Deduction appro��ed in the amount of:
r� . '��
�
COUNTY AUDITOR
20 20 20
County Auditor
Is the property in question:
❑ Real Roperty ❑ Mobile Home pC 61.
Has this dedudion been requested on
property for current yeaRO Yes❑ No
20
Date
�
certify under the penalty oi perjury that the above and foregoing informalion is true and correcl and thal lhe applicants was / were
lent of Indiana and owner of the afprementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
�\\ � � MI IAddress of authorized person
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