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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
Wit;; FOR DEDUCTION FROM ASSESSED VALUATION g
—..+t State Fans 43709(R11/6-09) 1
Prescribed by Department of Local Government Finance �!s
File a
INSTRUCTIONS: k1d �,/1
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. Fot Uu ` V Z 0�3
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. 0 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 I�[Y/ILCS t�rr".•+er
GIBS e�
See reverse side for additional instructions and qualifications. / 4N COUNTY�UDITOK
Ap..,,. ti. •-r croon buyer-see on reverse side) SC
Value '� nu ben/ al.S'ption Record number Page number
�� 'ago-a3w co3. 9a 2- 0�-/ do/3 . 3/ 2
of real propery as of Mortgage/Contract indebtedness unpaid as of Mortgage I indebtedness unpaid as of Ls the appl�t the sob nt year March 1,current year date of ap legal or equitable owns?
❑ Yes ❑ 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 apit:can4 indicate below Is property in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(1C 6-1.1-7)
Name of mortgagee or contract seller
•
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
1/4L S 1/21 036- S -/az /, / 7/ AC
Address of assignee(number and street city,state,and ZIP code)
Does applicant own property in any other If yes,what county? • What Taxing District? Has this deduction been requested on property
county in Indiana? ❑ Yes ❑ No for current year ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20_ 20 20
Signature of County Auditor • 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/contract buyer of the aforementioned property on date application is filed.
re(oloww'`n�_e-rs({�f�W'^y�n'at�-m�e)) Date(nonti,day,year)
FullTtrsident address of applicant(number and street city,state,and ZIP code)
I. `n�. to lA) C)to 5. 0Ax-so.Ile xf, 47G(05
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 dry,state,and ZIP code) .