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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
frifliti to/ OR DEDUCTION FROM ASSESSED VALUATION
Stara Forth x3709(R11/S-09)Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: I
Form a'• PPI r- I
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. • County 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 ! •.• • •••`v @ _nr)iir
See reverse site for additional instructions and qualifications. GI ' ' • 1 0 OR
Apprr
owner contract buyer-see side)
,,
Tan • I'-,-• n mber/legal desoip" , Record number Page nun
c G-�2-o '/act?-xq..T42- Oa2 o2/3
(§,0-
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of is the applicant the sole
Mardi 1,onetit year March 1,o neat year date of?p Ilona do legal or table
�/ Yes 0 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 is different than that of applicant,indicate below Is the pioperty in question:Annually Assessed
eel Property ❑Annually Assessed
i Mobile Home(lC 6-1.1-7)
(T7,777,_i
Name of mortgagee or contract seller -'�'
Address of mortgagee or contract seer(nra and city state,and ZIP code)
Name of assignee or other owner or holder of mortgage ^ 2 i /
Address of assignee(non C.+ .t/1CS
Dees applicant own prop f What Taxing District? Has this deduction been requested on property
county in Indiana? for current year? ❑ Yes
❑ No
zzi3 5yo 7 t,otTOR
Deduction approved In ih r
20 at 1 20 1 20 20 120 20
Signature of County Auditor - County Date(month,day,year)
I
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 I contract buyer of the aforementioned property on date application is filed.
Jn :re(owrrers fug name) Date(month,day,year)
,c,„ /of p �u u loo IX l�ith I\ si l r lappi (number . Keen state,qrd ZIP Goode) LH( �7O
Person authorized by duly ail
executed Power of itorney or byyIICI-rfsf 11..11--1112-0.7 LOA"„Ifi�( I Date(month,day,year)
Address of authorized person (number and street,city,sore,and ZIP code) . I