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i i ""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
1\i' FOR DEDUCTION FROM ASSESSED VALUATION � Year
`• ` j State Form 43709 (R6 / 5461 ' - �
��� Resai6ed by Depertment of Local Gwemment Finarxe
� 20�/
INSTRUCTIONS: � File Mark
To be (iled in person o� 6y mail� with lhe County Auditor of the county where the propeRy is /ocated. ,Q�
Filing Dates: 1) Real Property: Dunng the 12 months before ,lune 11 of the year the deduction is
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2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 of the yea� t �tlbNR4T�Fbe eflective.
See �everse side for additional instructions and qualifications.
Applicant
VL!J
Assessed value of real property as
Marrh 1, curtent year
no, what is his / her exad share of interest?
If name on
on
Key number / legal description
� /�_-���?�- Od/.9a}
MoAgage / Contrad indebtedness unpaid �
March 1, cunenl year �. 0�
that of applicani, indicate below:
Record
number
Is the applicant the sole legal or
owneR ❑ Yes ❑ No
owned with someone other than spouse, indicate with whom.
V
mortgagee or contrad seller
�
Address o! mortgagee or contrad seller (number d street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of easignee (number and street, city, sfate, ZIP code)
61.
Does appfitant own property in any other If yes, what county? What T; Dra���er NO.°?OO� ,-, •� �9� led on
countK.in Indiana? ;❑ No
_,.
Card i` . ......:. •••••
/� a
COUNTYAUDITC e��.7 � �.��.��SO�CG�'
approved in the amouni of:
20 O� I 20
/
Signature _
� I 20 20 I 20
County Auditor
20
20
� We certify under ihe penalry of perjury ihat lhe above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Full resident address of
G
,G .�
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
person