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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township 1 Year
FOR DEDUCTION FROM ASSESSED VALUATION
r" f'.. State Form 43709(R71/6-09)
Prescribed by Department of Local Government Finance ,
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INSTRUCTIONS:
Farm filed with:
7o be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.MA p r--�
Filing Dates: I) Real Property Must file during the year for which the deduction is sought. O LY U�unry Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months
before March 31 of each year the deduction is sought - ❑ County Recorder
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See reverse side for additional instructions and qualficatdns. G lB$O r ���1�r
Ap (owner or contract buyer-see restrictions oereverseside) NCOUNIYAUDITOR
a � � tea ,
T District Keynumber/legal desaipdon Record number Page number
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Assessed value of real property as of I Mortgage/Contact indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,anent year March 1,current year date of application legal or equitable owner?
) 3LI a o 0 ❑ 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 dnierent than that of applicant.indicate below Is the property in question:Annually Assessed
❑Real Property ❑Annually Assam
• Mobile Home(IC 61.1-7)
Name of mortgagee or contact seller
Address of mortgagee or contract seller(number and street city state,and ZIP code)
Name of assignee or other owner or holder of mortgage
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Ad of ast ee(number and street,city,state,and ZIP code)
Nw A 5 - 3 _ / , .DD 4 c
Does applicant own property in any other 1 If yes,what county? • what Taxing District? Has this deduction been requested on property _
county in Indiana? -- ---�- - for aurerd year?❑ Yes ❑ No ❑ Yes ❑ No
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COUNTY AUDITOR PAL jr 3-
U G2eG2 'r�J a
ed
Duction approved in the amount of. /
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20 20 20 20
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SignaturGof County Auditor - `' County
I I We certify under the/ of pperjjury- that w�v�the♦above and foregoing information is true and correct and that me applicant u a iv_www...,...._....__.._
owner-/contract jbuu/yer m nbonn property on date application is filed. -
Slg ...(',,,1. � � SLee Date(egret;day,year)s Fug en - a t number t a1Y,state,crud Z/P 13014 cii. Ili (.4701.4v
Person 411i41 tutted by duly executed Pourer of Attorney or by IC 6-1.1.-1214 Date(month,day,yea,)
Address of autha¢N person (number and street Gay,state,and ZIP code) .