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r��-,. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County I Township Year I FOR DEDUCTION FROM ASSESSED VALUATION
t: State Form 43709(R11/6-09)
Prescribed by Department of Local Government Finance 1 ,
INSTRUCTIONS:
To be filed in person or by mad with the County Auditor or County Recorder of the county where the property is Iocated.JUL 1 ` IJ I S
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. u Courtly 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. 'ecorder
See reverse side for additional instructions and qualifications. I tern.
Ap t(ow_ner or contract bwj%r-see restri• • ,•on reverse side) '�r�r y/r'�`'p—�r�� C1660N COUNTY AUDITOR
ra is> CJ Key number/do legal desmpton A 1< r/ Record number Page number
iz a !�- /l- �•� �03_ 0o d . yoY _o1 b� a ♦ 3RRU
Assessed value at real popery as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
Marts 1,anent year March 1,current r date of application legal or equitable owner?
ICk9 ❑ Yee ❑ 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 appfrant,indicate below. Is the property in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller w s - •-
Address of mortgagee or contract seller(number annd—streeV`4 city..state,and ZIP code)
Name of assignee or other owner or holder of mortgage _-q- _
.20!•3
Drawer NO..
Address of assignee(number and street,city:state,and ZIP code) X�J�X'/
Does applicant own property in any other If yes,what county? • What' Card (N O. 3t s••r o
county in Indiana?
El yes ❑ No No
COUNTY AUDI)
Deduction approved in the amount of.
20 20 20 20 20 _ 20 20
Sigrei County Date(rnorall,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 l .ntract buyer of the. . -mentioned property on date application is filed.
re. Date(month,day,year)
Y
t .
Ful / :•-r and-...b age,statq and ZIP code)
•(/ 21/ r- a114-am, i - — Y7G a
authorized by duly executed Power of- • • or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code) .
•