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`�.a� ,4,-:� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count' Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
0 State Forth 43709(R11/6-09)
Presaibed by Department of Local Government Finance MAY 0 8 TA
File Mark
INSTRUCTIONS:
b be filed in person or by mail with the County Auditor or County Recorder of the county whecg( sated. Font filed with:
Ring Dates: f) Real Property Must file during the year for which the deduction is N I�I ,e
2) Mobile/Manufactured Homes not assessed as Real Property Mus% �tA( Mk i2fr)>$TO R ❑�3eunty Auditor
before March 31 of each year the deduction is sought ❑ County Recorder
See reverse for additional instructions and qualiT (ions.
/011 •buyer-
side)
Tad � /legal description Record y[bpr Paggtb�g6-1J-3341 W-co I. /G [
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Ceased indebtedness unpaid as of Is the applicant the sole
March 1,coned year March 1,current year //Yy�� date of application legal or equitable owner?
�O�oW ❑ Yes ❑ NO
If no.what's 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 property in question:Amway Assessed
❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or convect seller n `0`/9
Address of mortgagee or contract setter(number and street city,state,:
i I'A Rck4 Ri'Wn-EN
other Name of assignee or oth owner or holder of mortgage n
Address of assignee(number and street,cry:state,and ZIP code)
CVAIs(ilk t Ml3r#e45
Does applicant own property in any other If yes,what co tog'/ n,l �,( ��� ion been requested on property
❑ Yes ❑ No err I U'/ t/4i(]� y ❑ yes ❑ No
COUNTY AUDITOR
Deduction approved In the amount at
20 20 20 20 20 20 20
Signature of .. y •i r / County'Ito/ C Date(rno(monde-day, r)
I/ 'e ce • under the penalty of perjury that the above and foregoing information is true and coned and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
`/Syi`attatu .��a t l:1 '� / Date(month,day,year)
/Flu resid t address of applicant(numberaaf street, ZIP code)
\e Y313 S. PSo kl a, d C , ii,3 • `h Io l�b
Person authorized by duty&seated Power of A ` Date(month,day,year)
Address of authorized person (number and street sly,state,and ZIP code)