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�„ . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESSl'IE'intIEH ' ship Year
I=
I`s' '4-.; FOR DEDUCTION FROM ASSESSED VALUATION
�t'."--'-' � State Form 43709(R11/6-09)
L ' 9 ' .
`��Q'Js Prescribed by Department of Local Government Finance i7
File Mark
INSTRUCTIONS: �.-. •
7b be filed in person or by mail with the County Auditor or County Recorder of the county where the property" :.- Q
i/�I:• fled with:
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought G9(y�M,t1f�G(�LINT? A ' 2oRjulty Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the fwrrzT T71oRtris Country Recorder
before March 31 of each year the deduction is sought ID
See reverse side for additional instructions and qualifications.
P.ppGCard(owner or 1 see re ski /2_00
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adi 7s ._'^n . I"ecord her Page
13 th, 0%- 1a-11b- /X- Got a6a-o7
any
Assessed value teal property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract bideoteaness in paid as of Is the approarlt the sole
Mandl 1,ahem year March 1,anent date of app&ration legal or equitable ownell
Z�CJ ❑ Yes ❑ No
If no,what is his/her exact share of interest? t If owned with someone other than spouse,indicate with whom
If name on record is different than that of applcanl.indicate below. Is the property in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Haile(IC 61.1-7)
Name of mortgagee or contract setter ,t-17 4034
i
Address of mortgagee or contract seller(number and sweet,city.state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and sweet city,state,and ZIP code)
Does applicant awn property in any other If yes,what county? • What Taring 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_ 20 20_ 20 20
Signature of County Auditor • County Date(month,day,year)
I I We certify 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.
netre es tuft ore) / at Date(month,day,yeah
Full resident address of a t(number a ndstreet city,state,
and ZIP code)
9yc/ IS-0 E--r
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street c1 state.and ZIP code)