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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Court 1 }'� it
t' FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R71/6-09)
Prescribed by Department of Local Government Finance
File y ark r �
INSTRUCTIONS:
Form � 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 Property.Must file during the year for which the deduction is sought GIE S M �. �rf��lt i .
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months o� O N ry Re�dA!£OR
before March 31 of each year the deduction is sought. �Y
See rove . side for additional instructions and qualifications.
Ap•.•.• lQ buys/-see"side)
T . . GL 7GI�f-C,/IC.Key number/ �� Record rapper P e n ben
.,.. 1 ar id-o?-oloi- oast /oa-61072 1 / 7�Assessed value of real popery as of rtgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole March 1,and year rdi 1,anent year data of ej�LOn legal or equitalie none/!
❑ Yes ❑ No 7 020
If no,what's his I her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is drfensit than that of applicant,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 l / Li
Address of mortgagee or contract seller(number and••••,state,and ZIP code)
Name of assignee or other owner or holder of mortgage .
Address of assignee(number and street city,slate,and ZIP code)
Does applicant own property in any other If yes,what county? • What Taxing District? Has this deduction been requested on property
aunty in Indiana? ❑ Yes ❑ No for current year?
❑ Yes ❑ No
COUNTY AUDITOR
Deduclion approved In the amount at .
20 20 20 20 �} 20
Drawer NO...c20.13 _
Signature of County Auditor 4 Year)
I/We certify under the penalty of perjury that the above and foregoing i Card NO. 1 1 n 7 9 ident of Indiana and
owner/contract buyer of the aforementioned property on date applicati /l() _- 1 en O. „/t.,w
SIBS �l�j �U �"^' 4Yt0
I /�/v/ZOl3
F dent dress of a uant(number a •street,city,state,a.•ZIP...-
.r 6 _J.(' e:. ei/•dG r /r✓ 1(967C)
Person authorized by duty executed•• - of Attorney 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) .