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z _ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun�{ s
FOR DEDUCTION FROM ASSESSED VALUATION 1 I r �{J r
- j- State Form 43709(R11/6-09) .A �J tl
-{.- Prescribed by Department of Local Government rmance A I qg
INSTRUCTIONS:
AU TI rirl`2013
Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.
Filing Dates: 1) Real Properly:Must file during the year for which the deduction is sought. 1 iii • ditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months l/nr(r".
before March3/of each year the deduction is sought - GIBSO'J C! Nciolkii9fIc&R
See reverse side for additional instructions and qualifications.
Appa ant(ownnr contract buyer-see restrictions ens reverse side) ti
i- SU,* as 1 ti -C3—AV
Taring it 144 number/I I desorption Record number Page number
eat" . ,. taf, - I`l- LT - - nr,l , 11 '- N1 aDI3 'Il&L
Assessed value of real properly as a Mortgage/Contta t indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as at Is the appMant the sole
March 1.anent year March 1,current n�ent year date of application legal or equitable owner?
ef. b •• as'es ❑ 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's(lament than that of applicant,indicate below. (ls perty in question:Annually Assessed
:yews Property ❑Annually Assessed
Mobile Home QC 6-1.1-7)
Name
am\ or aotraa seller
��tt-. —
Address of mortgagee or contract setter(number and street city.#ate,and ZIP code) —
Name of assignee or other owner or holder of mortgage _ -- V
AC
Address of assignee(number and street,ay.sfe
a ,and ZIP code) 5 ��
�u �'' ' . 0 IC;3
Does applicant own property in any other If yes,what county? - Vi I t on property
county in Indiana? ,—,/7
❑ yes �tJo
COUNTY AUD
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature 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 I contract buye of the aforementioned property on date application is filed.
�lfSigrature 7 Q�A/pWgr/r�/m /sj'�/a�C[/J6/�/a• / fy / /-7)&41,9 Date(nosh,day year)
i T Aril.� / Uwrf t(nyN4erantlO /I:M" [/7/ _in
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 I f Date(month,day,year)
Address of authorized person (number and street city state,and ZIP code)