Mortgage_Sisk „t'�° , STATEMENT OF MORTGAGE OR CONTRACT INDEBTE County Township Year -
FOR DEDUCTION FROM ASSESSED VALU
State Form 43709(R„/6.09) .
-=-/ Prescribed by Department of Local Govemment Finance
File Mark
INSTRUCTIONS: (n�[[((' 2 10V3
1 To be filed in person or by mail with the County Auditor or County Recorder of the phelje where the Form tiled with:
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 Properly Must du• He(12)month) IUnNL ry
before March 31 of each year the deduction a sought NTy AUDITOR t-t County Recorder
See reverse side for additional instructions and qualifications. OIRSON COU
Applt:ant(owner or mnbap buyer-see on reverse side)
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�p � IvC/J 'ruanber/legal descriPbon Record number Page number
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appgcent the sole
March 1,arrant year March tI.rten�O� date of appri:ation I legal ❑ �e O
0 no,what is his I her exact share of interest? 7 tf owned with someone other than spouse.i Indicate with whom
If name on record is different than that of applicant,indicate below s the property in questm:Annual;Assessed
eal Property ❑Annually Assessed
• I Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller Q�/ \
Address of mortgagee or contract seller(number and saee4 city,state,and ZIP code) �_
Name of assignee or other rwmer or holder of mortgage 1/43.215
Address of assignee(number and street,city state,and ZIP code) l
Yvv Y A.
Does applicant own property in any other If yes,what county? - •Whr /� WC Perry .
county in Indiana?
—
El Yes • No ��� ❑ No
It,.!/-� 7t7L�l� s 2
COUNTY AUDITOR .
Deduction approved in the amount of:
20 20 20 20 20 20 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/contract buyer of the aforementioned property on date application is filed.
Signature(owners fW name) Date(north,day,year)
{ -.,Q
Full recant address of applicant(number and street,city state,and ZIP code) _
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Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 r 'Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code) -
I