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a�•* STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS oun �^' F-0wn ip Year
F� .,, FOR DEDUCTION FROM ASSESSED VALUATION � J�LJ
State Fwm 43709 (RB / 2-07) C
�'�;, •� Presaibetl by DeOartmenl of Local Govemment Finance DEC U ���
File Mark
INSTRUCTIONS: `-�,
To be (led in person or by mail wRh the County Auditor o/ fhe cowty wheie the pioperty is located. � %'!� �,� �
Filing Dates: 1) Real Property: Dunng the 12 monfhs be/ore June 17 0/ the year the deducBon is fo be eRective.
2) MoBile Homes assessed under IC 67.7J: Befween January 15 and March 2 01 fhe year the de�fif.}iorr�isto be eflectiiie�ITOR
See reverse side Id additional insWcUons a� qualificatrons.
Ta�drg
or mnLad buyer - see restnctions on reverse
K� �-- a -�oa -aoo. s a. 3-o a- �_
hssessed value of real property as oF Mart�h 1. ament y�r Morlgage I ContraC indeWetlriess unpaid as of March 1, Is Ihe
. artenl year ^ �. ^ � b .
y �;
d
on recatl is tli(feren� Ihan �hal of applicani, indimte below:
Name of mortgagee or canUaG sNler
Address of mortgagee w cmUact sellar (numbe� and sfreet, dty, sfa(e. arM ZIP code)
Name of assignee a ather w:ner or hdder of matgege
AdNess of assi9nee (number aM sfreef, city, state. errd ZIP oode)
applitant own poperty in any dhe�
y in Indianal
❑ Yes ❑ No
ction approved in the amount of:
20 � 20 _
yes,
20
wmeone olher ihan spouse,
number
with whom.
or eGUitaae o«nen
❑Yes ❑No
_ � Is lhe property in question: .
ne QC 61.
DrawerNOaCQO..� :�0��
.�
— C8C(� v� . .....................
-�3��'9���0.��
T� poP�Y
� fw wnerd yea(1
❑ Yes ❑ No
AUDROR
p_ I 20 I 20
Dale (manth. dey,
20
I/ We certity under the penalty of perjury tliat the above and foregoing infwmation is true and correct and that the applicants was I were a resident of
Indiana and ovmer of the atorementioned property on March 1, 20
�awre (o s r,ni ne ) oa+e (monu. aar. r�e
7�n e W . ,��'I
by duty ezealed
r end sUeet. cify. sf . aiMZIP cntle)
St. � i. /�i�r�� ,T�/ y76 �/�
or
Address M au1Mr¢ed pelsm (nwnDei end streel, My. state, aM ZIP croCe)
oste (monur, aar. ree�