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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION C�un Township Year
�. w� / State Form 43709 (RS / d-03) � i�
�,�� Prescri�ed oy Depanmen; of Local Guvemment Finance
JUN 1 2 2006
INSTRUCTIONS: File Maric
To be filed in person or by mail with the County Auditor o) tAe counry where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 montAs before May 11 of the year the deduction is t��eirffectrve"��.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and MarchQ�g�ej7�ear�tt�e.�fed��ti��s to be ef(ective.
See reverse side !or additional instructions and qualifications.
Applicant (owner o ontract buyer - see�tridi s n ieverse side
Taui�istrid Key number / legal description Record number �� /
�.o
Assessed value of real properiy as of
March 1, curtent year
If ao, what is his / her exact share of interest?
%1' Q_ h� 1 �//1 _ 07� Page number
v u lJ � Tv v
Mortgage / Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, current year ��' O'�,l owneR ❑ Yes ❑ No
�-Ob oa uv
If owned with someone other than spouse, indicate with whom.
If name on record is diHerent Ihan lhat of applicanf, indicate below:
�me of mortgagee or contrad seller '
I�M'w n..4_
Address of mortgagee or contrad seller (number and 5t2e city, state,
❑ Real Property ❑ Mobile Hane (IC 61.1-�
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code; �--
Dra�ver nip.o?Q�J
Does a licant own ro e �•:�S`
pp p p rty in any other If vPS. what county �3ion been requested on
county in Indiana? C71-d 1\*�, urent yeaR� Yes❑ No
--- � __ . ....
COUNTY AUDITOR
Deduction approved in the amount of:
zo p , I 20
Signature
�j� I 20� I 2� I 20
� P
County Auditor
20
Date
20
We certify under the penalty of perjury that the above and foregoing infortnation is true and corted and that the applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
name)
Person authorized by duly execuled Power of Attomey
or by IC 6-1.1-12-.07
6-�n 6 �Address of authorized person