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; i���aa, STATEMENT OF MORTGAGE OR CONTRACT INDcBTEDNESS
'i'��; FOR DEDUCTION FROM ASSESSED VALUATION , Count Townshi Year
� M� -! State Form 43709 (R6 / 5-06) - - '
Presaibed by Depatlment of Local Govemmem Finance
INSTRUCTIONS: .JAN O i9 �0�8
To be filed in pe�son or by mail with the County Auditor of the county where the�property is located. � `��y �
Filing Dates: 1) Real Property: Dunng the 12 months befo2 ,lune I1 0/ the year the deduction is to be eflecYiGe!
2J Mobile Homes assessed unde� lC 6-1.1 J: Between January 15 and March 2 0l the y�gf�0p��d� ���ec(ive.
See �everse side for additional instnictions and qualifications.
Apptican o4vnerorcontract buyer- sg restnctions on reve�se ide)
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Taxin Disirid Key numbeY / legal description Record number
° ala-rR- os-3o�-00'!; . ao0�7--:.
�j,t���� Sa/ ^O � o Page number 3 3� '
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Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of . Is the applicant the sole legal or equitable
March 1, curtent year March 1,-current year , owneR 0 Yes ❑ No '
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If no, whaf is his / her exact share of interest? If owned with someone olher lhan spouse, indicate with whom.
If name on record is different than thaf of applicant, indicate below: Is the property in question:
❑ Real Properry O Mobile Horne pC 61.1-�
�e of mortgagee or contract seller
�KS� :. �' � � � -- - ---- —
Address of mortgagee or contract selier (number and st2et, city, tate, ZIP
Name of assignee or other owner or holder of mortgage DI"��5'eC ��0 �w� •••�� �•�
Address of assignee (number and street, city, state, ZIP code) C� 1'(i,� 0,: c .::....:.....
W.,c.�, �an o
�f 00
Does applicant own property in any other If yes, what counry? What Taxi „__..._.. ..� .����!'at,w � een requested on
county in Indiana? property for current yeaR 0 Yes ❑ No
COUNTY AUDITOR
i
Deduction approved in the amount of:
20 _ O � 20 � 20 20 20 20 � 20
Signature County Auditor Dale
We cer)ify under the penalty of perjury that the above and foregoing informalion is true and corred and that the applicants was / were
eside6i of In 'ana o r of the aforementioned property on March 1, 20
Sign _ te'(owne Person authorized by duly executed Power of Attomey
�'� u --QC�J or by IC 6-1.1-12-.07
Full resid nt ddfy ss of appli nt Address of authorized person
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