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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION oun Township Year
's / State Fwm 43709 (R5/4-03) � . �
a. �� Presaibed Ey Department of Local Govemment Finance �
wsrRUCnorvs: APR 2 � 20t�6
File Mark
To be filed in person or 6y mail with the County Auditor o/ the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months befo2 May 11 of the year the deduclion is to 6e� �f.%w
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of (��� t��tiH�G�s1�h6e eHective.
See reverse side for additional instnrctions and qualificafions.
orcont2c( gdy�r- see restnctions on reverse side)
Taxing Distn'd Key number / legal description Record number
(JO �
�� /}�� Q���� (� Page number / 3 p n I
vc.i � 7
Assessed alue of rea roperty as o Mortgage / Contract indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, current year March 1, wrrent year owneR ❑ Yes ❑ No
W �
Ii no, what is his / her exact share of interesl? I owned with someone other than spouse, indicate with whom.
If name on record is different than that of appliwnl, indicate below: Is the property in question:
of mortgagee or contract seller
Address of mortgagee or contrad seller (number and street,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st�eet, city, sfate, ZIP code)
ooeRR PP-- -- - ({" �e:cY �f- �,,,�.., _ / -- �
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countyin o�OVI�-�Q ��, &S' ��
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Deductic
20
SignaWre
❑ Real PropeAy ❑ Mobite Home (IC 61.1-�
state, ZIP
What Taxing Districl? Has this dedudion been requested on
property for current yea(? � Yes ❑ No
� O Q�p ^� 3�p OUNTY AUDITOR
o �
20 D�
�
20 L�q 20 20
�
County Auditor
20
20
certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
!enl of Indiana and owner of the aforementioned property on March 1, 20
Person authorized b�
or by IC 6-1.1-12-.07
ofauthorized person
f-6 - y�66s
Attomey