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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Ye
L�w� J State Form 43709 (RS / 4-03)
� PresaiEed oy Departmnnt of Local Gcivemment Finance � �
wsrRUCriorvs J�� �� 2006
To 6e filed in person or 6y mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During fhe 12 months be7ore May 11 0/ the year the deduction is to be eflective. ,�%�
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the de uc itf�s• o�bE"G6�ffective.
See reverse side for additional instructions and qualifications. f31B9bN C6UNTY AUDITOR
Applicant
Taxing
contract
Assessed value of real property as of
March 1, current year
on 2verse side)
K umber / legal description Record number
� -/0�.o7-/oI-ooGi 6�9- o.z8
`%/ Q_ �.-yr�/ //Q_ ��T Page number
d! / LC/CO / / CJc�
�
MoAgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current ye /� O� owneR ❑ Yes ❑ No
�Q /
If �io, what is his / her exad share of interesl? � r If owned with
I
If name on record is different lhan ihat of applicant, indicate below:
,me of mortgagee or contrad seller ��
Address of mortgagee or contrad seller (number d sf2et, city, state, ZIP
assignee or other owner or holder of mortgage
Address of assignee (number and stre�t, city,
Does applicant own property in any othPr � If �•;
county ir Indiana?
Deduction approved in ihe amount of:
r� i -
Signature
�).
slate. ZIP code)
1� �
other than spouse, indicate with whom.
Is the property
❑ Real Proper
�� ° � — `i-b 33
Dra���er NO ...................
Card NO. .5���....
/c_..
� o-�-<�r - -�� � o �
20��'T 20 � 20
P ---�
Couniy Auditor
0 Mobile Hortie (IC 61.
ias this deduction been requested on
�roperty for wrreM yeaR ❑ Yes ❑ No
20
Date
20
We ceRify under �he panalty of penur� �hai thP above and foreaoino informeGOn is true and corted and that the applicants was / were
resirient of Indiana and owner of the aforementioned property on March 1, 20
r•amr�)
R.�
Nor-EY� 1�ro�tit�e� flve.
Person aulhnrized by duly execuled Power of Ntlomey
or by IG 6-1J-12-.07
authorized person