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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
f" State Form 43709(R71/6-09)
Prescribed by Depamnem of Local Govermrem Finance
F ILE D
INSTRUCTIONS:
To be filed in Form filed with:
person or by mail with the County Auditor or County Recorder of the county where the property is located.
Filing Dates: 1) Real Properly Must file during the year for which the deduction is sought A P ti.r211;3,uditor .
2) Mobile/Manufactured Homes not atuesed as Real Property Must file during the twelve(12)months
before March 31 of each year the deduction is sought ❑ County Recorder
1 • •
See reverse side for additional instructions and qualifications. Ii. fii)ia
Apploa r orconuactpuyer- restrictions on aside) ` OUNTY AUDITOR
Taxi istrirl re �b �J01 iP- 103 QDO. t eo - 0 A& R�aa, 3 P�1 �7 1
Assessed value of real properly as of Mortgage/Contract indebtedness unpaid as of MortgageCOniract ebtedness unpaid as of Is the applicant the sole
March 1,current year Mardi 1,current year date of legal or equitable owner?
•
Y 6p(J 0 ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other dan sp ws%indicate with whom
If name on record is different than that of applicant,indicate below. Is the property in question:Annually Assessed
. p Real Property ❑Annually Assessed
/ ��/'�� Mo�bile�Homee(IC 6-li-7)
Name of mortgagee y wntra;t saber, 6 P 1 v v • !��444-"rV---•
Addres of mortgagee or contract seller(numb eet coy.state,and ZIP code)_ F
Name of assignee or other owner or holder of mortgage
Address of amgneg(ny mbar and sage 'ry,state.and ZIP co 3 /\) I
Oces appfirant ow/n/r property in any other If yes,what my? What Taxing District? 020)3--
`� 13_ /d
county in Indiana?
❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 I 20 I 20
Signs h re of �����, County Date(rtonN.tlal:Y�r)
I/We certify under the penalty of�perjui y that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
• .- . buyer of the aforementioned property on date application is filed.
�/ Sig 4. p ) / - Date(month,day,ste
A- 1-'Mi:- AL .s. and ZIP y� _1 `) VII (0'70
f-4—/�.3 -
Fl .-
` t..•��� — number
t0e \ZI\ e_ 1 7 1k 1 �
Person authorized by duty executed Power of Attorney or by 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street.dry,state,and ZIP code)