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.�-=�'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou" own ip Year
°5`� FOR DEDUCTION FROM ASSESSED VALUATION
Slate Pwm 43709 (RB / 2-07) D E C 5
s��y�. � Presaibed by Departmenl of Local Govemmenl Finance �oo�
INSTRUCTIONS: �� ��I�a�
To 6e filed in person or by mail wifh the CountyAuditor of the county where the property is /ocated. �
Wing Dates: 7) Real Property: During the 12 months befcve June 11 o/the year the deduttion is to be eRec6ve.16SON COUNTY AUDITOR
2J Mobile Homes assessed under IC 6-7.7-7: Behveen January 75 and March 2 0/ the year the deduction is fo be eflective.
See reverse side (a addi6onal insWctions arM qualifications.
Appl�cam (owner w y6ntre�tpryQ1� - see
artenl y�r
whal is his I her ezacl share of interest9
If �me rn recard is ditFerenl ihan
�o-� �-u
�9a9e / Coniract
,, wnent'�—�
below:
Name ot mortgagee or conlracl sell �/'� [�
i- �' '/ �
Address of mortgagee w mnlraC seller ( DeranA sfreet dty. sfate, arM ZlPcnde)
Name of asv9rree ar oiha avirer or hdtler ot morlgage
Atldress of asvg�e (number eiM sGeet city. state.
Does applirant oan praperty in any otner
counry in Indiana?
❑ Yes ❑ No
Oeduction appmved in the amount oi:
��+1"��
I/ We certify un�r the penairy
Indiana and owner of the afore
�,�ture @w�/s lull name)
�s. wn� �,�ry>
zo
�b-{n�.(�Q3'Oa./ ��� 3 � 7-S
aedness unpaid as oi Marct� 1, Is ihe app6ont Ihe sde legal d equitable owneR
Q � ❑Yes ❑ No
It owned wM someme dher lhan spouse, i�dicate wi�h whom.
Is Ue property in queslion:
❑ Real Pmperty ❑ Mobile Harie (IC 61.
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D,��„��,� �o...�.�.o�.:3..a��
�lT� Czrd NO
�dy��r-cy
:K�D1:I V/3�1�1167:i
�
zo _
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LlYes L� No
zo ,� 20 _
that the above and foregoing intwmatan is true and correct and that Ne applicants was / were a resident oi
property on March 1, 20
appliwnt (number antl sfreet. city. stale. arM ZIP cade)
� l� o �l.i �C��eJls�� � �e ,
ily executed Power of Ntnmey a by IC 61.1-12-.07
Address of autlor¢ed person (number antl sfreet.
Dale (monN. daY. Y�A
r�n