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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
�;; FOR DEDUCTION FROM ASSESSED VALUATION
t State Form 43709(R71/fi-09)
Prescribed by Department of Local Government Finance F I L • ,a
INSTRUCTIONS: LE
To be filed in person or by mail with the Court Auditor or County Recorder of the court where the m FO$ filed 1
Filing Dates: 1) Real Properly h is county P party is locatedAR 26x01 ,
party:Must file during the year for which the deduction is sought my Auditor
2) Mobile/Manufactured Homes not assessed as Real Properly Must file during the twelve(12)months
before March 31 of each year the deduction is sought. . • n r -ender
i....1•t
See reverse side for additional instructions and qualifications.
CIBSON'COUNTY AUDITOR
Appfi (owxr�ro✓r�mnt4 buyer on /'1 .:
rdistrifitActtain` {/_/{4 p>n C / t tlesa p nn �/ Record number Page nun_ N ge, - e23 /� - �DO - 001. 0 }- 1-6 A-Y 20/3 / e/
. a sired property as of Mortgage/Contract indebtedness unpaid as of Mortgage t Contact indebtedness unpaid as of Is the appri ant the sole current year March 1,anent year date of apPG ton legal or equitable owner?
�
j ono , ❑ Yes ❑ No
If no.what is his/her exact share of interest? ITdwned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below. Is perty in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
L-7.14.0.0-111-W--1
Address of mortgagee or contract seller(number and 4 state,and ZIP code))
Name of assignee or other owner or holder of mortgage
Addre s of assignee(number and sheet,city,state,and ZIP code)
ooes a Ll�rindil� / 7
Does applicant property i y other if yes,what county? What Taxing C"----^— , .____I Has this deduction been requested on property
county in Indiana? -- _o-Yes ❑ No 1
r_ -"h
COUNTY AUDITOR Drawer °l)/ 3
Deduction approved in the amount of-. D1.1111'(.'1 NO...................
20 20 20 20 C:1 I'd NO ..../.9 g
Signa of County Audimr • - County -.�/(Q5 f ll� .: •..•..
4/
I We certify under the pens of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Inman a,ed
�oowner{Igc»oyntract buyer of the aforementioned property on date application is filed-
t Sg/ratio— /J �7 Data(month,tar.year)
/��, /270 s.ntj' e and
Art 4 c3y,state,a L n 4.GQS / ,
Person authorized by duly executed Power of Atorney or by IC 6-1.1-12-03 Date(month,day,year)
Address of authorized person (number and street,ay,state,and ZIP code) \n`'*v'