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�e; �� � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�•s = FOR DEDUCTION FROM ASSESSED VALUATION
L . w� /� Sute Fortn 43709 (R6 / 5-06) � � �
� Presaibed by DepaNnent of Local Govemrtrent Finance
INSTRUCTIONS:
Township Year
' DEC 2 � �OU7
File a
To 6e liled in person o� by mail with lhe County Auditor of the county where the property is.located. �j �
Filing Dates: 1) Real P�operty: Du�ng the 12 months befo2 ,lune 17 of fhe year [he deduction is to be ef(ecliJe, 'a(�/
2) Mobile Homes assessed unde� IC 6-1.1 J: Between January 15 and Ma�ch 2 of the ye�d�80'l9dgFJ(g�qY�tQ �tive.
See �everse side (or additional inslruclions and qualifications.
Ap 'cant (ownerorcontract buyer- see restrictions on reverse side) �� %� ���% -
�/' lN.�(/"�✓ .
Taxing Distrid ' `C Key number legal description • Record number �'� � 7
� - /, - O/ ^ y O � — page number
Day�./�.�-o� yS �7
Assessed value of real roperty as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
Mardi 1, current year March 1, current year � ownef? '�❑ Yes 0 No
/9��Odt7
If no, what is his / her exact share of interest? If owned with someone otherthan spouse,-indicate with whom.
If name on record is different than that of appticant, indicale betow: - '^��_ ^��ro� �� �� �<_����� - -
. � 61.1-�
�e of mortgagee or conVad seller �/� ^ oD� ��J
DPa15'�I' ����....:.. . �
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Address of moAgagee or wntraG seller (number and street, city, state, ZIP
... � �t'(11��. ..
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Name of assignee or other owner or holder of mortgage ���''� UU � , 3/�/C W
�
Address of assignee (num6er and street, city, sfate, ZIP code) •
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for curtent year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in fhe amounl of:
20�_ 20 20 20 20 20 20
�
Signature County Auditor Date
We certiy under the penalry of perjury lhat the above and foregoing infortnation is true and corred and that the applicants was / were
., resident of Indiana and owner of the aforemenlioned property on March 1, 20
Signature (owners (ull name) Person authorized by duty executed Power of Attomey
�! or by IC 6-1.1-12-.07
( Full resi nt ddres of applicant , D(�f�uU�I Address of authorized person
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