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�aa "°� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'+'�; FOR DEDUCTION FROM ASSESSED VALUATION C n T p Year
�.,w -i StateFortn43709(R6/S06) . .. .
Prescribed by Departmen� of Local Govemment Finance
INSTRUCTIONS: � �-y,, File Maric
To be filed in person or by mail with the County Auditor of the county where the p�operty is located. �'`� ��
Filing Dates: 7) Real Property: Dunng the� 12 months befo2 ,lune 17 of fhe year the deduction is to be ��.COU NTy AUDITclR
- 2) Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 of the year the deducGon is to be e7fective.
See �everse side for additiona/ instruc[ions and quali(ications.
Applicant wner or contract buyer- see restrictions on reverse side)
Taxing District ` number / legal description Record number .� �
/� ) o�� '���o- �/�- /p0 -OOC�. •�- Pagenumber �� g
w /� -d/ ��
Assessed value real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March, i, current year March 1, current year ownert ❑ Yes ❑ No
l's D o'D
If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
o-�-t, , . 0 - 5
If name on record is different than that of applicant, indicate below: � Is the property in question:
� __ •_ � Real Property ❑ Mobife Home QC 61.1-�
me of mortgagee or contraIX seller --� _
(1-�—� � /�6�T
Address of mortgagee or conVad selier (number and street, ciry, state, ZIP Dra�ti�er \TO ��� 6 s-/�
Name of assignee'or other owner or holder of mortgage C8 C(j \T�. "—
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Dislrict? Has lhis dedudlon been requested on
county in Indiana? property for curtent yeaR � Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
zo 05 zo 0 9 zo Zo zo zo Zo
� P
Signature County Auditor Date
We certify under the penalty of perjury that the above and foregoing infortnation is lrue and correct and that Ihe applicants was / were
� resident of Indiana and owner of the aforemenlioned property on March 1, 20
Si nature (owners full name) Person authorized by duly executed Power of Attomey
�' c �- or by IC 6-1.7-12-.07
F II resident address of appli nt Address of authorized person
`13,58 N. eo4,,� Rd, 7�5E F�ah�� �o