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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
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FOR DEDUCTION FROM ASSESSED VALUATION r
_ ,, , Slate Form 43709(R11/6-09) �
Prescribed by Department of Local Government Finance lllllt
File Mark
INSTRUCTIONS: ^m^ s
Fomi Red . r t
To be tided in person or by mail with the CountyAuditor or County Recorder of the county where the property R located.
Fiirng Dates: 1) Real Property.Must file during the year for which the deduction is sought County Au•itor
2)Mobile/Manufactured Homes not assessed as Real Property.Must file during the twelve(12)months , i d -
before March 31 of each year the deduction is sought Mi °dJ-1!'-7"• .er
See reverse side for additional instructions and qualifications. GIB• _, -. - - • • -
AppGrant(owner mmVradb err-see reverse side) .�p��
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T ing District Key number/legal description J Record?timber Page number
,� JO aL- la- o`1 - `t - - odo.-_ o - or3g t k-I058
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of is the appOmnt the sole
March 1:anent year MMaarrdd�i 1,assent year date of eppgcatto legal or stable owndl
If ro,what Is his/her exact share of interest? 3�i h oD If owned with someone other than 'es ❑ No
spouse,indicate with whom
If name on record is different than that of applicant.Indicate below. Is property in question:Annually Assessed
eel Property ❑AnnualyAssessed
Motile Home(IC 6-1.1-7)
-
ya(ne of nangagee or contract seller
CO 11�� •
Adddress o ee or mnuad 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,coy,state,and ZIP code)
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Does applicant own property in any other r{-{} If yes,what county? • ' S on property
courtly m Indiana? ❑ Yes LY'NO Built ��r*�' (es ❑ No
COUNTY /4 CIO 58
Deduction approved in the amount of - �'
20 20 20 20 20 20 20
Signature of Comty •Auditor - County - N._ Date.(nanth,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 I contract buyer of the aforementioned property on date application is filed.
Signature(owner's full name)/( rt `/� Date(month,day,year)
F�resident address ofa Cpplcanjn�tt(number sbee�ytcr�•state,,fcu111 ZZI+Pcodde))
Iy`�Jw 7o'f S. jig ! ' r rel Mccft,a, :fo, &471.7.
Person authorized by duty exea,ted Power of Aldeney or by IC 611.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state,end ZIP code)