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4�y, . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Col rt ii1i�iMEA Year
FOR DEDUCTION FROM ASSESSED VALUATION Sr
State Form 43709(R11/6-09)
Prescribed by Department of Lad Government Finance f
INSTRUCTIONS: 0 L T le &13
To be filed in person or by mail with the County Auditor or County Recorder of the county where the Farm road vrim:
Pe Y h h Y property a located. •Filing Dates: 1) Real Property:Must fife during the year for which the deduction is sought. ' 2 0
2)Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)m�g((b(7 ������c' ty Auditor
before March31 of each year the deduction is sought - 1pl k3SON CO 2 YC6W{yOWRier
See reverse side for additional instructions and qualifications.
Applicant(ou+p(a(contracrbuyer-s restnc'liionc r verse side)IC
T.\' ` �'..o f�ID ` _ Key nnumber/ description cont R number Page number
•mI.>•value et real property as of Mortgage/Contract indebtedness unpaid
n�9 t>ad as of Mortgage/Con'va' Frailness unpaid as of Is the applicant the sole
1,oral year Ma 1.cement year date of application legal or table owneR
POI es ❑ No
If no,what is ba!her exact share of interest? 4 if owned with someone other than spouse,indicate with whom \\
If name on record is different than that of applicant.indicate below the property in question:Annually Assessed
ea!Property ❑Annually Assessed
• Motile Horne QC 6-1.1-7)
Name of ee or contract seller /1
-LJ R� 117 LP A t r( � •
Address of mortgagee or contract seller(number and street city,state,and ZIP code) /_� 1/_ --
Name of assignee or other owner or holder of mortgage I J SSCM t mP 2 y k
•
Address of assignee(number and street,city,state,and ZIP code) �f-1 J G�
Dees applicant property in any other rrrmmt��--��/���)TT""""'' If yes,what county? • l� �J l J ed cart property
❑ Yes 4 4o es ❑ No
' COUNT _.
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.
'SSii\ggnnatue((owners MI Moo lm�`) Date(month,day,year)
u0 n�'Eenladtlr O appticani t(number and (city,state,and ZIP code)
n3-1 LC) 1200 } tALGAdc,-1, SIJ 4l(03°)
-*toothed by duly executed Power of Attartoy or by IC 6-t.t-12-0.7 Date(month,day,year)
Address of authorized person (number and street oily,state,and ZIP code)