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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Court c(i`_!l tiir=ray .
mss;;: FOR DEDUCTION FROM ASSESSED VALUATION't�
� State Fomi 43709(R11/6-09)
AUG 1.3 2 113
Prescribed by Department of Lo Government Finance
Local
File Mark
INSTRUCTIONS: may,� r
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. F
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. GIB JON0Ow,IJ*y®g}ITOR
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 - ❑ County Recorder
See reverse side for additional instructions and qualifications.
Applicant •r or cont;77-s-•re.• ,.. p(rdverse side)
Ta;lib _Et I C////C/li'Gi
: ,VA---) —Key umber/eg- a�t -/off- coo. a�9 o a 57 ` o, j� 5
value of real property as of (�/ Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the aPpOcant the sole
.A..,• 1,torrent March 1,anent
year year date of ap tion legal or equitable owner?
off/ ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with ne other. :n spouse,indicate with whom
If name on record is ddferent than that of appO ant,indicate below'. Is property in question:Annually Assessed
Real Property ❑Mobile Home s61.7-7)
Name of mortgagee or mny5er
fnx
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage /1 /� /_ r /4
Address of assignee(number and street,city,state,and ZIP code) 1/y^,///(nom(/,%/ (/ /T�j
Does applicant awn property in any other If yes,what county? • What Taxing District? Has this deduction been requested on property
county in Indiana? for current year
El Yes ❑ No ❑ Yes ❑ No
---— — - --- - 1!AUDITOR
Deduction appm
207 ` • 20 20 20
Drawer Signature of Cow. :s I County Date(month,day.year)
Card NO. ••
I I We certify t ation is true and correct and that the applicant is a resident of Indiana and
owner I contra __.__,...rc..y tai eate application is filed. --...
Sig - -(owner's :nay; Date(month,day,year)I r a�i
F . r,-.ent address of.Al et(number;A:1.0street a1) state,and ZIP code)
X • -S�s-1 ,' 5,04. Atu 5Jet /S,ll H'7/234
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-03 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)