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f : STATEMENT OF MORTGAGE OR CONTRAC DF S County Township I Year I
2 FOR DEDUCTION FROM ASSESSED VALUANr
%c`_: tt State Form 43709(R11/6-09)
Prescribed by Department of Local Government Finance 1 UL 2'2-20 13
J File Mark
INSTRUCTIONS:
Form Ned with
To be filed in person or by mail with the County Auditor or County Recorder of the county {•re the yr.•.••••i, rs located.
Filing Dates: 1) Real Property Must file during the year for which the deduction is so •r I i/mm.' �r�R
2)Mobile/Manufactured Homes not assessed as Real Property Must file •• ••. tiltlrfBlS ❑ County Auditor
before March 31 of each year the deduction is sought o%BSO ❑ County Recorder
See revers side for additional instructions and qualifications.
Apcowner Wontmat/ ar-seo restrrso $side)_
a Key number umber I legal description
/� Record nun P e nummber
Assessed value=foa=l as of 2 l�—J/-10 -/d )- do / /O'3 -ea yr / 67Q
A seh 1.anuet Wopery Motgage/Contract indebtedness unpaid ardf Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
year March 1,=rent year date of application legal or equitable owner?
7600C) El yes El No
If no,what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is dReneft than that of applicant,indicate below property in question:Annually Assessed
X
eel Proms ❑Annually Assessed
Mobile Home(IC 6-l.1-7)
Name of mortgagee or=tract seal ,
Address of mortgagee or contract seller(nun r and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city state,and ZIP code) —___�iy�t�/C�.---
Does applicant own property in any other If yes,what county? • What Tax a" ./ J
county in Indiana? r A p
El Yes ❑ No �/1-l.
COUNTY AUDITOR /3-3( r7
ai
Deduction approved bi the amount of
20 20 20 20 20 20 20
Signalize 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
owner/contract buyer of the aforementioned property on date application is filed.
reOwin-'e'('(s1`/-7`'dtl'.-name) s J�I�J Daattee(month,day,year)•Full resident address o(a t number of sbller.a7y��jjsate,and ZIP-cyo-tle) / - a a - �3
) ) ) p) , a1 1t Qv{. .n t.nt t b-p tcinn
Person authorized by duty exeared Power of Attorney or by IC 6-1.1-12-03 / Date(month,day,year)
Address of authorized person (number and street city sate,and ZIP code)