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=a- STATEMENT OF MORTGAGE OR CONTRACT 1 ES,S unty Township Year .
;:s FOR DEDUCTION FROM ASSESSED VALUATI1
l State Form 43709(R11/6-09)
'•z �.e Presented by Deparmrer of Local Government Finance .
JUN 1 File Mark
INSTRUCTIONS: 4 2013
Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.
Filing Dates: 1) Real Property Must file during the year for which the deduction is sough . p �/� 8 County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file 2)months County Recorder
before March31 of each year the deduction is sought 011380N COUNTY AUDITOR
See reverse side for additional
instructions and qualifications.
Appgcant(owner orcon.D��see L \at�
W_ CUM a a\ lk /yyK
_
-1-a - DiStliCt Key number/legal description
Record nut Pac number
O2-1,—IQ-30-/OI -cottv77 -Ode-( 1 3?
value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract Indebtedness unpaid as of Is the applicant the sole
1,current year March 1,wrreCRo date of application legal or equitable owner?
\_J`\h.1�\ l�i'lyJ, ❑ Yes ❑ No
If ro,what's his/her exact share of interest? H owned with someone other than spouse,Indcate with whom
If name on record is different than that of applicant.indicate below Is the property in question:Mnuagy Assessed
p Real Property ❑Annually Assessed
Mobile Home QC 6-1.1-7)
Name of mortgagee or contract sager /�a
Address of mortgagee or contract seder(number and street,city,sate,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and sheet city,sate,and ZIP code)
Does applicant own property in any other If yes,what county? . What Taxing 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
SyrtabaelomtYAWi' ' / (' County Date(nmor(Ym,dayieg /2
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
• er I contract buyer of the aforementioned property on date application is filed.
Slg tl re(owner's f u g name C I Date(month,day,year)
1\ Ate . __._
ent address of a••cant(n mber and striae a>):sat ,and II code)
•35r, C /50E 7z7c )vJ P� • (7 �7� 35)
Person authored by duty executed Power pt Attorney or by IC 5-t-1-12-0.7 / Date(nonfh,day,year)
Address of authorized person (number and sheet rdt1:state,and LP code)