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aa STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS ITonn Year
' i4 FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R11/5.09)
Prescribed by Department of Local Government Finance ,1 �C 1
INSTRUCTIONS: APR FO /Irk
To be filed in person or by mad with the County Auditor or County Recorder of the county where the
Form fled with:
Y ty ry property is located.
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. • a •.. . -uditor
2) Mobile/Manufactured Homes not assessed as Real Property Must tile during the twelve(12 month• , • i":.y/st
before March 31 of each year the deduction is sought. ( IBSON C UN~ gUDI ty ecorder
See reverse side for additional instructions and qualifications.
Applicant wireror contactbuyer-seere stAcbo son reverse side)
see
CO 1 744" .<9 Le_JA-QA...fC_.
Toxin District Key number/legal description Record number Page number
2.40 - 3 —19- /0 / - 00/. 5i .1 /- co c/ Ao i 3 / 90 SI
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the applicant the sole
March 1,one year March 1,current year date of ap
drO legal or equitable owner?
O 0 D ❑ Yes El 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 appbcant,indicate below: Is the property in question:Annually Assessed
[lead Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller S [3
Address of mortgagee or contract seller(number and t,city,state,and ZIP code) I (/��� /� �^
Name of assignee or other owner or holder of mortgage I •.0L At l n 1• E p P�� C
Add of assignee(number and street,city,state,and ZIP code) I "L ll
a dm-Litt
Does appti t own property in any other If yes,what county? What Taxing C I
county in Indiana? I
❑ Yes ❑ No j A yDn b L>)
COUNTY AUDITOR I / r (�r-� Cam) F
Deduction approved h the amount of. I t��J y Smr ;2 /�Mk
20 20 20 20 / l/ (�-� 1
Signature County I �01 I
3 - iqbq )
I/We certify under the penalty of perjury that the above and foregoing information is t/
owner/contract buyer of the aforementioned property on date application is filed. -----_-__
t� Sig (owners fufl name) Date(monui: ,��
-/V`
,,' y(Full � f app& t(nu p\and street,drys.sttaaJte,a ,/ill Pco�de))p-� C'
S authorized VVV Pd 2 fAtlaneFaymbylC6-1.1-12-0.7\ w uti11�� IN (—l�� � Date(mo rtm.day,
Address of authorized person (number and street,city,state,and ZIP code)