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.-.„c., STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
'II.�.'-f_ FOR DEDUCTION FROM ASSESSED VALUATION
State Forth 43709(R11/6-09)
Prescribed by Department of Lod Government Finance F Y • . :f)(
INSTRUCTIONS: 1 a F/ ��
iI
Form tied with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property timed.
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought Lr C 1. 1 g 2)13 0 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 - I ❑ County Recorder
See reverse side for additional instructions and qualifications. �n 7�
A 15Int on reverse-a-A) / '� �[plttSON COUNTY AUDITOR
Tari D Key number/legal description (.GJ Record number Page number
,26, _ /3 - a.lo - yoo - 000 . 3 l,/- ooh /3 Solt
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Convect indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year date of appimtlon legal or equitable owner?
94, no 1 ID Yes ❑ No
lino.what is his/her exact share of interest? / If owned with someone other than spouse,Indicate with whom
I-
If name on record is different than that of applicant,indicate below. Is the property in question:Annually Assessed
❑Real Property ❑A nualhy Assessed
1.1-7)
Name of mortgagee or contract seller /3
Address of mortgagee or contract seller(number and street ay,state.and ZIP code) II i
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Name of assignee or other owner or holder of mortgage 1 —'^7>� , TO L.J4 I1 O/-)
AS e4 icy c-"
Address of assignee(number and steel,cot):state,and ZIP code) I(,/�
pr
Does applicant own property in any other If yes,what county? • What Taxing D.__ 1-I SO I /
county in Indiana? ❑ Yes
❑ No I m I_, _
COUNTY AUDITOR ∎I
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor Z I - County Date(month,day,year)
I/We/We certify 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.
X SS�I'y,1ArTr fiA7 naep/pfi)f��nik) t ket(0 /�/,jpa'y� (alit �1� / �j( � / (��
IIJ� 10 /s �/OnumglrandaU T l{I Xec �Q (ilUVO
Person authorized duly executed Power of 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)