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aT STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS roggi'un Year
FOR DEDUCTION FROM ASSESSED VALUATION
Y., �-
. State Form 43709(R11/6-09)
: • a 1
Prescribed by Department of Local Government Finance _
File Mark
INSTRUCTIONS:
r._.c .
To be filed in person or by mail with the County Auditor or County Recorder of the county Where the property is local-•', . !n11�r
Filing Dates: 1) Real Property:Must tile during the year for which the deduction is sought. *Si. AQ�9h-�,6yitor
2) Mobile/Manufactured Homes not assessed as Real Property:Must tile during the twelve(1n aeon
COUN before March 31 of each year the deduction is sought. - ••••• County Recorder
See reverse side for additional instructions and qualifications.
AppGpnt(owrrer/ and r side)
T v •'• r: �n//( / Key number//legall description Record number Page number
. P i aG �3-/3-330 -Q�J`da0a 07073 313-2
Assessed rape of real• „. as of Mortgage!Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appfi ant the sole
March 1,anent year March 1-°j�`� date of application legal or equitable owner?
(vn ❑ Yes ❑ No
If no.what Is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below Is rty in question:Annually Assessed
eel Property ❑A urartyAssessed
Move Home(IC 6-1.1-7)
Name of mortgagee or contract seller el —
Address of mortgagee or contract setter(number nd city,state.and ZIP code)
Name of assignee or other owner or holder of mortgage 070 1
Drawer NO
Address of assignee(number and street.city state,and ZIP code) Card NO. / / 2 2
Does applicant own property in any other If yes,what county? What T: �-(1 c/1 GG-- m
county in Indiana? /7//�) /(� ' r ID No ll!`�l /WI V' I No
%A SO T�� -C--n d7 /V COUNTY AUDITOR C?2 7/
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor - County Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
o/w/// ����t�namme) n/(/g Date(month,day,year)
yrill nt' address!/r/f,✓nt(u / t e b'\„/ n�
i-ef Person authorized by duly executed Power of Attorney or by IC 6-1.1-1tl-0.7 �”/-J
Date(month,day,year)
Address of authorized person (number and street.city-state,and ZIP code) .