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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Townshi Year
mss:: FOR DEDUCTION FROM ASSESSED VALUATION
State fvrtn 43709(R11/fi-09)
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: ■
lb 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 Properly Must file during the year for which the deduction is sought Coun • ditor
2)Mobile/Manufactured Homes not assessed as Real Property Must Re during the twelve(12)months ) �•
before March 31 of each year the deduction is sought - r Mil.
l!YL1ii'erorder
GIBS. _ . _ . . • -
See reverse side for additional instructions and qualifications. \
Applicant(owreror -.nee regriggvs m re e) A `
T �sbict/J'y,) Key number/dal description •�J �3 Record number Pa9� �
2� a -1 Sr- u7f ) 30od / 97 0Ot 14
Assessed valor d real property as of M.rtga e/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the apprint ii
March 1:anent fear March t++��orrtent Year date of aPPlcaCvr legal air equitable avnwll
L9 0 0 0 0 ❑ Yes ❑ No
It no,what is his/her exact share of Interest? If owned with someone other than spouse,indicate with whom
It name on record is difierer errIlt f applrant,indicate below. Is the property in question:Annually Assessed
U.Reat Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of contract sell ,//2 .
Address of mortgagee or contract seller(number and street,coy,state,and ZIP code)
Name of assignee or other owner or holder of mortgage 1 _-
Address of assignee(number and street city,state,end ZIP code) I G 1
ADoes applicant own property in any other If yes,what county? • WI I 1 — 4 '1 teeny
county in Indiana?
❑ Yes ❑ No ❑ No
COUNTY AUDITOR
Deduction approved in the amount of.
20 20_ 20 20 20_ 20 20
Signature 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.
Signature(c/e-Mina ) Date(month,day,year)
f �'//(//_/// ��//V/to/9
Full .. .: of ap nt(nt tm-ber street rely,state,and ZIP code)
'�.... 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 end street city,state,and ZIP code)