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���a �� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
i FOR DEDUCTION FROM.AS8ESSED VALUATION u T s ip Year
SUIe Fortn 43709 (R6 / 5-06) ' � � � °' - � . .
�
� Presaibed by Depanment of Local Govemment Finance
INSTRUCTIONS: File a�
To be filed in pe�son or by mail with the County Audito� of the county where the p�operty is locafed. �����/.
Filing Dates: 1) Real Propeny: During the 12 months be(ore June Il of the year the deduction is to 6eGe��COUNTY AWITOR
2J Mobile Homes assessed under IC 6-1_ 1-7: Between January 75 and March 2 of the year the deduction is to 6e eHective.
See �everse side lor additional instnictions and quali(ications.
Applicant (ownerorcontract buyer- ee restrictions on reverse side)
�fi 1',�X/Y1 �� Q711 Qrn d o /\
Tauing Distrid Key number / legal description
Assessed value of re:
March 1, current year
Record
Page number
a�-��-�a-voa-����o$-va Q�5
as of MoRgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or
March 1, current year owneR �❑ No '
y i�� �
If no, what is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
or contraIX seller
Address of mortgagee ar contract seller (number and street, city, state,
Name of assignee or
Address
owner or holder of mortgage
(number and stieet, city, state, ZIP code)
Ooes applicant own property in any other If yes, what county?
county in Indiana?
Deduction
20 �
�
Signature
in the amounf of:
20 D q 20
P
❑ Mobile Harne
Drawer NO...°°�`�.'.7.........
Cr1.
What Taxing Di: Card �T�. .. ��5, n
.........
r��� �8Y,�7�� '°
COUNTY AUDITOR
�
County Auditor
20
20
Date
20
We certify under ihe penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
(ull
address
� t.tii�/Le..c�
Person authorized by duly executed Power of Aftomey
or by IC 6-1.1-12-.07
aulhorized person