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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS I' .,,�,:�(-c. pa Year
ggq`---1' ,;; FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R77/6-09) d = -
Prescribed by Department of Lo Government Finance
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INSTRUCTIONS:
To be filed in person or mail with the Court Auditor or County Recorder of the county where the m is locat:. • F
Pe by h h h properly "�, , ilydfi%
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. .� U Coertn,rsuditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve CO L N D7 i vr.
before March 31 of each year the deduction is sought - r County Recorder
See reverse side for additional instructions and qualifications.
Appficanllpwner or comma buyer-see on reverse.side)
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Assessed value of real property as of Mortgage/Contact indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sae
March 1,anent year March I raiment year date of application legal or equitable owner?
1 0 1 000 ❑ 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.i dicat below. Is the property in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Namgq(r9pgg a contras sellerr .
C1-�Ull?2\ c
Address of rtwrgage seller(number and street ray,sate,and ZIP code) _ ___ —- —
Name of assignee or other owner or holder of mortgage
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Address of assignee(number and strestreet,clot,state,and ZIP code) J \' -� I
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Does applicant own property in any other If yes,what county? - t property
county in Indiana?
El yes
❑ NO ❑ No
n — — . — . COUNTY, /3 -0705(.° .
Deduction approved in the amount of.
20 20 20_ 20 20 20 20
Signabre of County Auditor • County Date(month,day,year)
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
ow7ner/contract buyer of the aforementioned property on date application is filed.
Sl`gn aalr e(owngras full ram) Jm� ��/-/y� /,�!/M�� god/�/,//�/�/lI� —//�� U -/,,(� Date(month,day,year)
FW i t OadQrtssh/ of a, an( A� nerdstreet.aty%state,! (Jf �N ? (�-/ . 4 I 7V' L .
Person authorized by dulyy executed Powii=orney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street afy,state,and ZIP code) •