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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Comity Township Year
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,;: FOR DEDUCTION FROM ASSESSED VALUATION I
11. State Fond 43709(R11/609) �g�,'
: Prescribed by Department of Local Government Finance 1 I FI
INSTRUCTIONS:
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. ff11'�•Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. I O T 28d3nty 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. - ❑ County Recorder
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See reverse side for additional instructions and qualifications. % V h
Apprc{�i (owner or contact buyie/r(` ee on verse side) • - • • • ` AUDITOR•
Taring Isis ~ - Key number desaiption I Record number Page number
Da-' a caco - lcl-/g - 3 oil _ 000, 3/ / - oo ) ao /3 55a �
Assessed value of real of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appicent the sole
March 1,ante year March 1,current year D date of application legal or equitable
O O I a Yes
No
I
If no.what is his/her exact share of interest? m owned with someone other than spouse,indicate with whom
If name on record is dfterent than that of applicant.indicate below: Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
I Mobile Home(IC 6-1.1-7)
Name of mortgageer contract sell
Address of mortgagee or contract settler(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
•
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? El Yes ❑ No for current year? ❑ Yes
❑ No
I
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20_ 20 20 120 20
I
Signs au of County I Date(roudr,day,year)
I/We certify under the penalty of perjury ttha_✓tlthe tabove 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 (owner's name) _ / Date(month.day,year)
/,\�F resident address of applicant(number and city,stare,and ZIP code) •
A. 3)q W DWI<it? i OAFLAmb C .4I -I-A-) q-7tr4D
Person author zed by duly executed Power 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)