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STATEMENT OF MORTGAGE OR CONTRACT I E I C� my Township I Year
FOR DEDUCTION FROM ASSESSED VALUATI g!
State Forth 43709(R11/649)
Prescribed by Department of Local Government Finance
AUG g 20 4 File Mark
INSTRUCTIONS: Flinn fled with.
To be filed in person or by mail with the County Auditor or County Recorder of the county whe the pro•-rty • ed.
Ming Dates: 1) Real Property.Must file during the year for which the deduction is sought r,lly►r - County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file du' "• — 1.11 •4 •g I pR
before March 31 of each year the deduction is sought GIB SON COON County Recorder
See reverse side for additional instructions and qualifications.
Ap t(owner buyer-see restriron inverse}
T D' sil Key number/legal description Record number Page number
la z(Q— la -0 5 - A-(Oo -cn 1 .S / D 00R —7 ROIL/ 307/0E?
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Conuaa indebtedness unpaid as of Is the applicant the sole
March 1.current year March 1,anent year date of application legal or equitable owner?
Q'9300 ❑ yes ❑ No
If no,what is his/her exact share of interest? I If owned with someone other than spouse,indicate with whom
If name on record is afferent than that of applicant tdhate bebw" Is the property in cuesdom Annually Assessed
tjarReal Property ❑Annually Assessed
Mobile Home QC 6-1.1-7)
Name of mortgagee or contras seller D7%43
Address of mortgagee or contract seller(number and street rdy,steno,and ZIP code) -
Name of assignee or other owner or holder of mortgage
CP
,�
Address of assignee(number and sweet bay,,state,and ZIP code) (l]
)5w-
Dee-applicant own property in any other If yes,v w •.••••• deduction been requested on property .
county in Indiana? ....No .• t year? .
❑ Yes 10,.••' ❑ Yes ❑ Na
P + Li 5 P 3-a -,0 cx p taw'et 3
Deduction approved in the amount at - o• •
IS Cat d
20 20 20 _ 20_ 20 20
Signalise of County Auditor • County Date(month,day.year)
I 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.
(owner's MU ) (/ Date(month.day,year)
`Ft �O' f a �'�s ao state,and LP code)
Fx0 decoaddress- (number and Poi
Person au 1? by duty eJri of Ac)(rn by IC 6-1.1-12-0.7 Data(month,day,year)
Address of authorized person (number and street sty,state.end ZIP code) .