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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
FOR DEDUCTION FROM ASSESSED VALUATION
1-1- Slate Form 43709(R71/6-09)
Prescribed by Department of rod Government Fran
FIL E13 .
INSTRUCTIONS: F
7u be filed in person or by mad with the County Auditor or County Recorder of the county where the property is located. 9 2013
Fling Dates: 1) Real Property:Must file during the year for which the deduction is sought. County Auditor
2) Mobile/Manufactured Homes not aeraesed as Real Property.Must file during the twelve(12)months
before March 31 of each year the deduction is sought - GI Cou.t R-0.--
E. _:.runt.
See reverse side for additional instructions and qualifications.
Appfrant(owner or ` _`Ir•� r �J / G18SON COUNTY.AUDITOR
97i7e)�'a. `% 7 s0_06°3.03z_oa 2 c O�3
Record number Page n wa
Assessed vabe of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
March 1,acres year March 1,current year data of application legal or equitable owner?
LW ❑ 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 property in question:Annually Assessed
Real Property ❑Annually Assessed 6-1.1-7)
. Mobile Home(IC Name of mortgagee cc contract seller !//4
Address of mortgagee or contract seller(number and street,city,state.and ZIP code)
Name of assignee or other comer or holder of mortgage
/0 t /7ais 0c5;90 I
Address of assignee(number and street,coy,state,and ZIP code) •
Does applicant own property in any other It yes,what caunty? • What Taxing District? Has this deduction been requested on property .
county in Indiana? ❑ Yes ❑ No for current year? ❑ Yes ❑ No -
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 I ___ I 20
_____--".'_''° .--'4 <:_f::.].c..__
Signature of County Auditor � � e(month,day,year)
Drawer NO c20 13
I/We certify under the penalty of perjury that the above ant t i; ,-t i_, • ' •t thnt is a resident of Indiana and
owner/contract buyer of the aforementioned property on d: • ., .7
s� N9-0
_ owner's rue name, _ NO. e(month,day,year) -
Am_ Card 1�0. �rI}
,/ F resident address of a,. . number and sheet,ay,,state,and 2 • • t J V D .I I.r. �.aMv.(X7
7% glob 5 '1ooE 17 /
Person authorized by duly executed Power of Attorney or by IC 6-T1-1 e(month,day,year)
talIJ/ETo Al lP-). g7& 70 r
I Address of authorized person (number and sheet city,state,and ZIP code)