Mortgage_Gayso (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
kin FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 /6W)
Prescribed by Department o(Local Government Finance FILE
File Mark
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor or County Recorder of the county Ale jh rp /ty is located. Form filed with:
Filing Dates: 1) Real Property Must tile during the year for which the deduction is sou It j T L U I J
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months County Auditor
before March 31 of each year the deduction is sought County Recorder
See reverse a .. additional instructio s and qualifications.
Apprcant(:,r.• a•. lab * -seee . .eons on re 'gee)) // ( I')BSONTCOUNTY AUDITOR
ivD •s 1 f 11 Key number/ Idesah tipq 6,—/ f —/OR-b/—OW. / Recordnumber Page number7y.
Assessed value of real property as of Mortgage/Co(nntt/trra/ct indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appplpnt the sole
March 1,current year March 1,arrmr�crveyar� date of application legal a epuitade owner?
(J b0 CO ❑ Yes ❑ No
If no,what a 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 the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
C/ / Mobile Home(IC 61 ,-7)
Name of mortgagee a contact seller
Address of mortgagee or contract seller(nun^___ ;state.and ZIP code)
v raw Cl \O••• aunty? What Taxing District? Has this deduction been requested on
' •"'• property
nt yea ❑ Yes
❑ No
'
Card
COUNTY AUDITOR
. .....a t e amount of
20 20 20 20 20 20 20
Signature of • ty •it; - Canty Date(month,day,year)
I 1 .
1/W- v-rtify 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.
Signature(owners hdl e) Date(month,day,year)
WI resident ad of apparent ntt(num nd street ally,state,and ZIP code)
fe, - chAt .$)- P &9i okposcie LO (1205-
Person authorized by duly executed Power of Attorney a by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code) .