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��V' } STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'' = FOR DEDUCTION FROM ASSESSED VALUATION Coun``�� gTownship Year
v, w� � State Fwm 43709 (R6 / SO6) ���
� Presvibetl by Department of Local Govemment Finance
INSTRUCTIONS: FEB � 1 7���a,�
To be frled in person or by mail with the County Auditoi o( the county where the property is located.
Filing Dates: 1) Real Property: Du�ng the 12 months before ,lune 17 of the yea� the deduction is to b �,+��!��
2) Mobile Homes assessed under lC 6-1.1-7: Between January 15 and March 2 o/���y� ��ctirfn'� (R6e elfective.
AUD O
See reverse side for additional instructions and qualifrcations.
Ap ' nt (owner or cpntiact buy - searesMc6ons on reverse side�
l.L/ C��
Taxing Dis Key number / legal description Record number vO �
, �-��-/7-io3 • obY•
a y� _O � D Page number C7�
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, cunent year a owneR � Yes ❑ No
73 g�39 °,
is his / her exad share of interest?
If name on record is difierent ihan that
of mortgagee or contrad
indicate below:
� �-
I( owned with someone other than spouse, indicate with whom.
Address of mortgagee or conVad seller (number and stieet, ciry, state, ZIP
assignee or other owner or holder of moRgage
Address of assignee (numberand st2et, city, state, ZIP
Dces applicant own property in any other If yes, what
county in Indiana?
Deduction approved in the amount of:
zo o zo � Zo
� /
Signature
COUNT
zo
County Auditor
Is lhe property in question:
❑ Real Properiy ❑ Mobile Horne pC 61.1-�
'"I
What Taxing Distrid? Has this deduction been requested on
- - --- -�-- `------. ..ear? � Yes ❑ No
Dra���er NO..°.?�Q�••;,��
CardNO . .....................
Q�e.r�j� �`� �3, 93p oa
,.. ,�.. �Zo
certify under the penaity of perjury lhat the above and foregoing information is We and corred and that lhe applicants was / were
leni of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners (ull name)
n .
Person authorized by duly executed Power
or by IC 6-1.1-12-.07
ient address of applicant Address of authorized person
E� OY� . O S� c�c � tY.e.'�O(� , sYJ �111a�7