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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
��,l,;� FOR DEDUCTION FROM ASSESSED VALUATION
"'•" State farm 43709(RI1/6-09)
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Prescribed by Department of Local Government Potence
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INSTRUCTIONS: ,q7 ned
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. J jr y 1U13
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. YU County 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. J)r /)Cot1�y-ReC6rder
See reverse for additional instructions and qualifications. JTf!`L'°,�°.'"Fr1Y.'Ti','W`T�C
Applicant or contract buyer-see --.'.r- J.core side) GID°ON COUNTY AUDITOR
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Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the apparent the sole
March 1,anne n year March 1,current year d;te application ^ legal or equitable owner?
5S?I4..)I ❑ Yes ❑ No
If no,what s his/her elect share of interest? If owned with someone other than spouse,indicate with Mwm
If name on record is 6Eerent than that of applIcanL indicate below Is property in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller (_ r> ` �(/
Address of mortgagee or contract seller(matter and street,city,state.and ZIP )
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street ray,state,and ZIP^^.t°1_ -11)/ 1 /1/ _ -.' YQ A'C
To .1Ud,l -�a
Does applicant own property in any other If :trio? Has this deduction been requested on PrtpenY
county in Indiana? ❑ Yes ❑ No VV for anent year? ❑ Yes ❑ No
Deduction approved in the amount at -N lS+.-1''rTl,
20 20 DLi_34 74/ 20 20 20 _
Signature of County Auditor I 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.
Signature(.)4 h t„ :me) ,, , Date(month,day,year)
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F.: Sad, of....�t mberard street ray,state,and ZIP code) \\
Perso, uth:araed by duly executed Power of Attorney or by IC 61-1-12-0-7 Date(marsh,day,year)
Address of authorized person (number and street dry.state,and ZIP code) •