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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count/it s ' bear
:' FOR DEDUCTION FROM ASSESSED VALUATION �r(��{gj{y�� �}}�p��State Farm 43709(R11/6-09) 1 p i, '.by Dent of m �t FiliJ .L�J
File Mark
INSTRUCTIONS: a • ! - r ,
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. un .}
2)Mobile/Manufactured Homes not assessed as Real Property Must Me during the twelve(12)months , �'�� i�.���
before March 31 of each year the deduction is sought. - e.
See reverse side for additional instructions and qualifications. GIBS• • • • - • • rr
Appfirant( uyer4 r- -" • / side) m
Taxing District mum.*I egal description Record mber Page
". %-13 - LIo4-COD . 420 - 6.016) 1 f
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the applicant e
Mardi 1,current year Marlin I t year date of application legal or equitable owner?
( VI ❑ Yes El No
If no,what's his I 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:Annualy Assessed
❑Real Property ❑Annually Assessed
Mobile Home QC 61.1-7)
Name of mortgagee or contract setter "r
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 dry,state,and ZIP code)
Does appl'ic for current own property in any other If yes,what county? • What Taxing District? deduction been requested on property
county in ❑ Yes ❑ No year? ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved to the amount oft
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.
(owner's fire name) ^ S
/`y���1 4�/y Date(( Y y year) ti
Fn C I (nu rand street pf};�te.and Zl • f f Z U —Jf
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state.and ZIP code)