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STATEMENT OF MORTGAGE OR CONTRACT I T NE Doun Township Year
;; FOR DEDUCTION FROM ASSESSED VALUATI N b a
State Form 43709(R11/6-09)
Presdibed by Department at Local Government Finance S E P 2 3 201?
File Mark
INSTRUCTIONS:
Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the county re the t is located.
Filing Dates: 1) Real Property Must file during the year for which the deduction is soup 21 County Auditor
2) Mobile/Manufactured Homes not a«VSed as Real Property tit§ qr 1toffef4 k
before March 31 of each year the deduction is sought ❑ County Recorder
See reverse side for additional instructions and qualifications.
Appgrant roc contract buyer-see resbicbons on reverse side)
CIaxi District yr a /`o `/Key numbealegal desolation Record number Page number
c�— ►a -I g- 0703- cue. X8'3 -oa K / 3 5oa -7
Assessed value of real property as of Mortgagge/Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the applicant the sole
March 1,armnl year Mardi 1,arnei n . 3 . date of appli auon legal w equyade owner?
/ ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than spouse,Indicate with whom -If name on record is driferent than that of appfcant indicate below. Is the property in question:Annually Assessed
pi Real Property ❑Annually Assessed
- Mobile Home(IC 61.1-7)
Name of gwkat tract seder
Address offf morrtcoo ttgagee�wirrtrad seller(number and street,city:state,and ZIP cock1 CUT ,
Name of assignee or other owner or holder of mortgage _ Q c H T --
�l I /E5Li
Address of assignee(number and street,dty:state,and ZIP code) /3—56
Does applicant own property in any other If yes,what county? -l aa QQ quested on property
county in Indiana? ❑ No /) u?�.1li ❑ yes
❑ Yes ❑ No
sS 1 070
Deduction approved in the amount of: ,
20 20 20 20 20 I 21.• 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 buyer of the aforementioned property on date application is filed.
,Sig (a rs full r(�rwmme) Date(mouth, 3r) .C3
Full resident address of appfcant(number and et,gay,state,and ZIP code)
r1a-22 . S. 5bnn I n)AKV C!,
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street dry,slate,and ZIP code)