Mortgage_Mason STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
t"
State Form 43709(R71/6-09)
Prescribed by Department of Local Government Finance
F LE Mark
INSTRUCTIONS:
To be filed in person or by mad with the County Auditor or County Recorder of the county where the property ca%J 20 orm filed with:
Filing Dates: 1) Real Properly Must file during the year for which the deduction is sought. ❑ County Auditor
2) Mobile/Manufactured Homes not assessed as Real Properly Must file during the twelve(12 months
before March 31 of each year the deduction is sought County Recorder
See reverse side for additional instructions and qualifications.
Ap m(a. bn, ere= re /r �Gl�N COUNTY AUDITOR
Ta Dist id Key�rturnbberrr//i^//legal desorption ftemrtl Page number
ate' /v oY- dS - ►ny - 000 . 39G -odd 3!0 '1 i
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contrast indebtedness unpaid as of Is the apprnant the sod
Mardi 1,anent year Mardi , Conn tract of appgcation legal or equitable owne?
9 ex,, g,3 ❑ Yes ❑ No
If no,what is his/her exact sham of interest? If owned with someone other than spouse,indicate with whom
If name on retrial is different than that of applicant,indicate below. Is the property in question:Annually Assessed
❑Real Property p Annually Assessed
Mobile Hone(1C 6-1.1-7)
Name of mortgagee or contract seller Dit
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Add of assignee(number and street c%state,and ZIP code)
i SE Nc D,r _i-ii 3A C,-
Dees applicant own property in any other If yes,what county? • What Taxing District? Has this deduction been requested on',meetly
county in Indiana? ❑ Yes for ante year?
❑ No ❑ Yes ❑ No
COUNTY AUDROR
Deduction approved In the amount of
20 20 20 20 20 20 20
Signature County Auditor !3\J / ' Courtly Date(month,day,year)
/W ceNfy 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.
xSig (owna/s f it A Q�4
X . Date(month,day,year)
Fu dent address of applicant Nn m and state, P cod
,5-(,-2 rc. c -, r , /.t/ V7666
Person authaiaed by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,yew)
Address of autha¢ed person (number and street city,state,and ZIP code)
•