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.� q'�A STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count T shi Y r
r,,..,._ � FOR DEDUCTION FROM ASSESSED VALUATION
' State Porm 43709 (R8 / 2-07)
's';.,. ' Presaibe0 by Depanment of Local Govemment Finarrcz
File Mark
wsrnucnoNS:
To 6e frled in person or by mad with fhe CountyAuditor o7 the county where fhe property is bcated. a� �Q
Fding Dates: 1J Real Property: Dunng the 72 montlrs be/ae June 77 0/ the yea� the deduction is to be eRec6ve. (J
2J Mobile Homes assessed under IC 6-7.7-7: Between January 75 and Ma/ch 2 o/the year the deduclion i�g� �NTY AUDITOR
See reverse side for addi6onal instiuctions and quali�cafions. �
�buyer -�see fes'NCtims a/ verse sde)
(%� � T 7
�-��-�
1, axren� y�r
what is ha / her enacl share of inte2sl?
reartl is difFermit Ihan lhat of applican4 ��dicate 6elov.'
Name of mortgagee or conLact selle��
-DO �{. � l 3 - o ,-�
c1 iMeWedneu unpaid as of March 1,
�! � 5 9 3
� If wmed with sort�eone ott
Atldress of rtartgagee or cmUaG seller (humber arrd slreeL tity. sfafe. and Z!P cnde)
Name of assgnee or dher wvner or holder of mortgage
Address of assignee (numbes aiM sVeet, city. sfafe, arid ZIP oode)
Doas applicaM own property in a,ry dher
counry in Indiana7
❑Yes ❑ No
�
appmved in the amount of:
ii��
Reoord number Page number
�ODCo l8�
Is �he apptimnt Ihe sde legal or equi�ade owne(
❑Yes ❑No
spouse. e�6pte wilh �nirom.
�Is ,i/he�� rry in O�lion:
YS R�I Prooertv ❑ Mobile Hrnne (IC 61
�'Drawer NO..�Q,Q,{p • /Q'a
yes. what counry7 Wha �n ProD�Y
Card NO. ❑ No
. ... . ..........�..� :
couNnauo��s/3 �j� �`�� �3/ �°
20 � 20 � 20 _ � 20
Daie (rtronfh. daY. Yea�
20
I IyJe certify unAer the penally of perjury that Ne above and foregoing infortnalion is We and cortect and that the applicanis was / were a resident of
II(dia}ia and owner of the a(orementirnetl property m March 1, 20
ot applicanl (num6er and slreet. cky, sfale. and Z/P code)
Person autlrorized by Euly ezecutcb Power of Atlorney or by
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stale. aM LP aode)
Dale (rmnlh daY. Y�A
�
Y��)