Mortgage_Hill (3) •
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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Court lrarMAI7 If!
FOR DEDUCTION FROM ASSESSED VALUATION
- - State Forst 43709(R11/6-09)
Presented by Department of Local Government Fiance
File Mark
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. F. il,7TT? •/ iril'
Filing Dates: 1) Real Property Must file during the year for which the deduction is sough( R ITO
2)Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months G I'SO
before March 31 of each year the deduction is sought - ❑ County Recorder
See reverse side for additional instructions and qualifications.
App6cant(Nr contract bb .r-.. - on reverse
Taxing District i' Key number/legal description Record number Page number tit
60. % .. _ ) . _ - ls • :-_a\-oCyO- L S9 - obi tar) 13 3-2.19
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
March 1,anent year Marts 1,atment year date of application legal or equitable owner?
'I - 1`t5 Ir/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
Ct9ea'CC
l Property ❑Annually Assessed
• Mobile Horne(IC 6-1.1-7)
N+2ame�of mortgagee or contract seller
Add of mortgagee or contract setter(number and save thy,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 other If yes,what county? - at Taxing District? I liar this den•' •- -
county in Indiana?
Yes ❑ No .-�\J
COUNTY AUDITOR D t.(v`.L+ - iS 0"
Deduction approved in the amount of:
D
20 20 20 20 20_ CaI-d N°'
Signature of County Auditor County
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/contract buyer of the aforementioned property on date application is filed.
naturer he name) s Date(month,day year)
Pull resident ad ‘applicant and(number and t,city, re,and ZIP code) /
1y{nom -/ff f• r,y ic1`C.e 1,e• /lg/C/.ur./Gi /i /A/ Y744&
Pmson authorized by duly executed Power of Attorney or by IC 6-1.1-12-D7 Date(month,day,year)
Address of authorized person (number and street dry,state,and ZIP code) •