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*-04.;....% STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
rF FOR DEDUCTION FROM ASSESSED VALUATION •
• ,±.'c;._I•t State Form 43709(R11/6-09)
Prescribed by Department of Local Govemment Finance '' _
INSTRUCTIONS: Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the properly is located. r{�� 1, ' sI "'
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought LZA County rZaki
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 - . County Recorder
/
See reverse sid for additional instructions and qualifications. O,T1ltrjm)j;
Applicant(ante contract buyer-see - i•y revPrrse�ide) (3IBSIN COUNTY AUDITOR
A . /) IV/
Taxing District :MI description Record Tqs Page n
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the^'
Match 1,aarrrif year March 1,cunpfLyBgr owner?
date of application legal or equitable owr?
Yl t ❑ Yes ❑ No
If no.what is 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:Annually Assessed
❑Real Property ❑Annually Assessed
Mobile Home(IC 611-7)
Name of mortgagee or contract seller V/� ttl !/J,n
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)
in any other If yes,wh. •- abort been requested on property .
County in applicant own property Y Drawer NO.... O�
county in Ind'ana? ' __ ar
❑ Yes ❑ No ❑ yes ❑ No
.
Card NO. .
Deduction approved in the amount of:
20 20 ' 20 20 20 20 20
Signature of County Auditor • County Date(month,day,year)
I/We •:• 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
J.ntrbuyer of the arementioned property on date application is filed.
act
ers MI -me) Date(month,day,year)
- Ati
F a!!%I y�...•6S�apyf«anl(num,.f:rdsae(40 state,and- kr �` `tI'V I 1176 J 9
Person authorized by duly executed Power of Attorney or by IC 6-1.1--1 1210--0.7 Date(month,day,year)
Address of authorized person (number and street ci y,state,and ZIP code) .