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. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Court' 11111E i�`(:.r
FOR DEDUCTION FROM ASSESSED VALUATION I _ , :�
-'r State Farm 43709(R11/6-09) ,
Prescribed by Department of Local Government Finance
NOM fir& 2013
INSTRUCTIONS:
with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. Form Nod
Filing Dates: 1) Real Property Must file dining the year for which the deduction is sought a ditDr
2) Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months m ���m'y`
before March 31 of each year the deduction is sought. - u BSON t:U raoht>A@Hdbr ?R
See reverse side for additional instructions and qualifications.
(• r or contract buyer-see on reverse side)
lazing D'�'. Key'V •.. /legal description
`Record number Page number
( 4 3_,Q_9 c � - 9- (b-3aa- ode ol° - (- 1•5-
D.0 k 3 5 (I % %
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness'unpaid as of Is the applicant the sole
March 1.current year March 1,co�yrent year data of application I legal or equitable owner?
S DO Yes No
If no,what is his/her exact share of interest? , If owned with someone other than spouse,indicate i with whom
If name on record is different than that of appbcan4 indicate below Is the property in question:Annually Assessed
real Property ❑Annually Assessed
I Motile Home(IC 6-l.1-7)
IsLaw of mortgagee or contract seller
G 4f�T
Address -n rtgagee or contract seller(number and street city,stare,and ZIP code) I
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 r� If yes,what county? • I What Taring District? ao..: ..
county in Indiana? ❑ Yes r NO NO.
J�raWer 1
COUNTY AUDITOR 5:41....FS"'
,,,.
Deduction approved in the amount of: . y ••.
Card ��•
20 20 20 20 20
*nave of County Auditor • County I 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. I
Synatu . :es•••nit : / I Date(mGh,day,year)
ent address• - t(number and street city,state,and ZIP code)••
2703 E /0 j Phi brand? !N y9&Vg
Person authorized by.. • ted Power of Attorney or by IC 6-1.1-12-0.7 I Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code) _