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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County h ' r
P ' 11. FOR DEDUCTION FROM ASSESSED VALUATION
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State Form 43709(R11/6-09)
Pr e:aiibed by Department of Local Government Finance
INSTRUCTIONS: D 1
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 filed
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought n - ••.:.
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months I'�• •r
before March 31 of each el■ N!!�1)•r'ecorder
year the GIBSIN •LINTY • • • ;
See reverse side for additional instructions and qualifications.
App6ran (owner a r:see restrictions on sole L44
T D Key num ?gal desaiption Record number P corn
- �a .bl- aar6 - t 5a1 .col ab ► � ;/21
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appkant the
March 1,anent year March 1,=rent year I date of application legal°O°[[[.e,,,qubable owner?
' 44a•57 Yes ❑ No
It no,what is his I her exact share of interest? It'tf owned with someone other than spouse,indicate with whom
If name on record is different than that of app?ant indicate below: Is rII thee,property in question:Annually Assessed
1 rill Properly El nn
Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(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? • /2 nperty
county in Indiana? 20/J
❑ Yes o .... ❑ No
COUNTY AUDI vl
Deduction approved in the amount of.
d I s
20 20 20 20
Cat'
I
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 I contract buyer of the aforementioned property on date application is filed.
Signature(owner's hull name) a Date(north,day,year)
�4rr\t L`- !Gtr 2+
F resident address of applicant(number and sheet city,state,and ZIP code)
-
tong 03 I a S-60 e F c r.-5 , --1-0 I-tf o ti q
authorized by duly executed Power of Attorney or by IC 6-t.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)