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/i � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
1\i�'FOR DEDUCTION FROM ASSESSED VALUATION Count Townsnip Year
,�
`'•. ��!' Stete Farm 43709 (R6/ S-06)
� Presaibed by Department of Lwal Govemment Finance
INSTRJCTIONS: � � �Flf�—IV1ar�
To be filed in person or 6y mail with the County Auditor of the county where the property is locate �•J ��
Filing Dates: 1) Real P�operty: During the 12 months 6efore ,lune 11 of !he year the deduction is to be eNective. nn7
2) Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 of the year f� �e�c�bars+tb be eflective.
See reverse side for additional instructions and qualrtications.
(ownei
Taxing Distrid
buyer-see
Assessed value of real property as of
March 1, current year
If no, what is his / her exact share of interest?
on
Key number / legal description � �� Record number O
��D�'W� OG• Da agenumber g�aa
Mortgage / Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
/ � -- ....
If owned with someone olher than spouse, indicate with whom.
If name on record is difierent than ihat of applicant, indicate below:
�me of mortgagee or contrad seller ����
Address of mortgagee or conVact seller (num er and street, city, state,
Name of assignee or other owner or holder of mortgage
of assignee (number and sf2et, city, state, ZIP code)
Dces appiicant own property in any other If yes, what county? What Tauing District?
county in Indiana?
20 _J r
Signature
appro� ed in the amount of:
� �,�
�I
COUNTY AUDITOR
20 0 20 20
�
County Auddor
Is the property in question:
❑ Real Property ❑ Mobite Home (IC 61.
.�
Has lhis deduction been requested on
property for current yeaR 0 Yes� No
�
20
' We certify under the penalty of perjury that the above and foregoing informalion is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signalure (Qwne/s full
of
, Fi L
s
or by IC 6-7.7-12-.07
4ddress ofauthorized person
a� 1[ 26 ? b
of Attomey