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.+.�•n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS � ToEiw4hip Year
,, ., ! FOR DEDUCTION FROM ASSESSED VALUATION g��.J
. Stale Fwm 43709 (R8l 2-07)
°�;y„ •� Presaibed by Oepahment of Local Govemment Finance D E 2� 2�0�
File Marfc
INSTRUCTIONS:
To be filed in person or by mail wdh the CountyAuditor o) the county wheie the propeAy is locafed. � �%6�+ ��
Fding Dafes: 7) Real Property: Dunng the 12 months before June 11 0/ the year the deduc6on is to 6e e/fec6ve. � DITOR
2) Mobile Homes assessed under IC 6-1.1-7: Belween January 15 end Ma2h 2 oflhe year the dedu�t@f6'to!U�e ed�Cb�.
See reverse side lw additional insWC6ons arid qualifications.
ic nl (owner w mnfrad buyer - see stncfims on reverse '�
�
Ta�drg Dislnd ' Ke n ber / legal descn ' n Record number Page number
- o3.'i�a�G - � �a
Assessed valu real pmpefty as ot March 1, nmenl y�r Mortgage / Coniretl indeWatlness unpaid as of March 7, Is the appGnnt Ure sole legal equ�uae amen
anrent year �/
p( Q('Q 0 ❑ Yes ❑ No
"^n, whal is h¢ / her exact share of irrterest? �f owned wiTh sameone oUrer ihan spouse, indicatc with wFam.
If name rn record is diflerenl Nan Nat of applicanl, intlipte below: Is Ihe property in Question:
❑ Real Pmperty obile Home (IC 61.1-7)
Nama of mortgagee or conlract seller
Adtlress of rtwrt9agee a co�Uad seiler (number sriaet. 'ty, sfafe, aM ZlPcotle) �
Name of asvgnee w olher owirer w hdder of matgage
Atldress ot assignee (n�cMer a�M sLeef. dty. �ate, and ZIP cvde)
Does appliwM own p�opeRy in any alher If yes, whffi counry? What Texing DisUictT Hes Utis deduclion been requested on poperty
counry in Indiana? tw anent yrv/7
❑Yes ❑ No ❑Yes ❑ No
COUNTYAUDROR
DeducUon apprwed in lhe amount of:
Zp 2p _ 20 _ 20 _ 20 _ 20 20 _
Signafure of CounN�d�� Counry Date (rtrantA, tlay, yea�
I/ We certify under the penalry of perjury that ihe above and fwegoing infortrwGOn is true and mrrect and tliat the applicanfs was I were a resident of
Indiana and owner oi the afwementioned property on March 7, 20
Sig wre (owne(s hdl na ) Date (monlA. tlaY.Y��
resi nl address of app�rrt (number end streef. crtyyate. aM Z e . - D ,
G d�1� , i 7 lo G� (e
Person authonzed by duy executed Power of Atinmey or by IC 61.7-t2-.07 �� (/��� �Y• Y��
AdCress at aulhor¢ed persan (number end sheet dfy. state. aM LP oode)