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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
FOR DEDUCTION FROM ASSESSED VALUATION �'� ,F,1-)
-u State Rum 43709(R71/6-09)
Prescribed by Department of local Government Finance
File Mark
INSTRUCTIONS: S E •-•. tad.Art'
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. 0 County Auditor
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 - 1 1, ,'"r: my Recorder
�
See reverse side for additional instructions and qualifications. G 1 B SO N • I ' ' ' 1 9 • '
Appfrant(owner or restricrions on cox ' )
� �Ta District Key number/legal description Record number Page number
a !o -oy a5 3od _ 000 . 6lx _o �o dO / Y 18SSJ
Assessed value of real property as of Mort gage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Marts 1,current year March 1,current year date of application legal or equitable owner?
015-0 to 0 ❑ Yes 0 No
If no.what is as/her exact share of interest? If owned with someone otter than spouse,indicate with whom
If name on record is afferent than that of applicant.indicate below Is the property in question:Annually Assessed
❑Real Property ❑MnuaM Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
J
Address of mortgagee or intact seller(number and street,city,slaw.and ZIP code) — — /,_/y/11 `'�f/( -—
Name of assignee or other tamer or holder of mortgage Drawer NO /i lo/ 1 �1
Address of •ghee(number and street,city.state,and L e) 1�� C
r7Q,�.,".. , tro-K 762 Card NO. 0 J
Does applicant own property in any other If yes,what county? I What Taxing District?
county in Indera? ❑ yes ❑ No
COUNTY AUDITOR - -
Deduraon approved in the amount of:
20 20 L 20_ 20 20 20 20 .
Sgn. d County Auditor, County Date(month_day,year)
I/We certify under a pen 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 data application is filed.
\
Signature(owner's lull name) Data(month,day,year)
k.V.Fua resident address of applicant(number and street,city:state,and ZIP code)
Person authorized by duly executed Power of Attorney or by IC 6-1A-12-0.7 Date(month,day,year)
Address of autha iced person (number and street,city,state,and ZIP code) .