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STATEMENT OF MORTGAGE OR CONTRACT IN l lE / unty Township Year
' FOR DEDUCTION FROM ASSESSED VALUATIO°4 State Form 43709(R11/5-09) JUN 18 2013
Prescribed M Department of Load Government Enrage
File Mark
INSTRUCTIONS:
4,_ I, ,'..r Form Iced witch
T o be filed i n person or by mad with the County Auditor or County Recorder of the county wh- ;y ;e�•ra� ,jet,
Ring Dates: 1) Real Property:Must file during the year for which the deduction is sought. .r,1�'�r�rr������NTN( AU�r11 OR En County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Mustece$Fdg`ore9 4 (12)months En
before March 31 of each year the deduction is sought. County Recorder
See reverse side for additional instructions and qualifications.
Applicant( or contract buyer- on reverse side)
rn� o-c - on
Ta isauY Key number/legal description n Record number P e number
rrnTo�n , aL-7_U-01 - loo 000 �7 � GUI 13 -a la (n
wade of real popery as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appEcant the sole
Mardi 1,anent year Marcholegent year date of application legal or equitable owne?
6J ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with sortwnne other than spouse,indicate with whom
It name on record is different than that of applicant,indicate below Is the property in question:Annually Assessed
seal Property ❑Annually Assessed 6-1.1-7)
- Mobile Horne(IC Name of mortgagee• .4,' seller
00
Address of mortgagee or contract seller(number a street city,stare,and ZIP code)
Name of assignee or other owner or holder of mortgage -
Address of assignee(number and sheet city state,and ZIP code) 141i,)' t
Does applicant own popery in any other If yes,what county? - P quested on property
county in Indiana? ❑ Yes {^' I
❑ No piD" � /�-� .] Yes ❑ No
COW / z -di `^W
Deduction approved N the amount at .J (n I' J
20 20 20 20_ f "') " / `.i 20
l/
Signature of County Auditor ..arty Date(month,day,year)
I/We certify under the penalty of perjury that the above and kilt-going 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.
$Ip (owner's lull .rpt Date(month,day,year)
F>0 /of a number t state,an ZIP code
a Q L? h
74 t
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(norm,day,year)
Address of authorized person (number and street city state,and ZIP code) .