Mortgage_Bond �.a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun wn pear
FOR DEDUCTION FROM ASSESSED VALUATION 1 p
...es--- State Form 43709(R11/6-09) I .a t� -I
Presm n
bed by Department of Lanai Government Finance I. C 4
INSTRUCTIONS: DE U��'dmt1
lb be filed i n person or b y mail w i t h the County Auditor or County R e c o r d e r of t h e c o u n t y where the property i s l o c a t e d. D C F a i n�d I
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought
2)Mobile/Manufactured Homes not assessed as Real Property Must Re during the twelve(12)months A.4 MtaR!lrj:. Recorder
before March 31 of each year the deduction is sought GIB `d„I .�_�_r_,h-l1.ijJ
/, � DITOC
See reverse side for additional instructions and qualifications. GIBSON C•UNIV.AUDITOR
Appfuant( or contract buyer- striations on reverse sire)
Q*t.)
Tad D Key number/legal desaiPtion Record number Page number
a� - 19- 3a - /ot-ooi 3r? G-oaY aoltt SXSa-
vato areal property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the appfirant the sole
1;anent year March 1,cement year date of application legal or equitable owner?
g coO ❑ Yes 0 N
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 appbcant,indicate below Is the in question:Annually Assessed
Real Property ❑AnnuallyAsessed
Mobile Home QC 6-1.1-7)
Name of mortgagee or contract setter v/ff(" jam �����j`t
Address of mortgagee or centred seller(number Wd street,cdy,state.and ZIP code)
Name of assignee or other owner or holder of mortgage 7�
Address of assignee(number steel city, te,and LP code) r .t S �/ D I a wa I- NO /07d ///777
Does applicant own property in any other If yes,what county?O•( What Taxing District? ��
county in Indian? ❑ Yes ❑ No Card NO. (((1...•���/�✓
COUNTY AUDITOR
Deduction approved in the amount ot.
•
20 20 20 20 20 20 20
-Signet of County Auditor . GFy / • County Date(month,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.
XSg/^/(5 re( mama Date(month,day,year)
( e Full ksideat address of applicant(number and sheet,o/):state,and ZIP code)
p coy/ f E;Sehnc,Je( L.-. ,1-F. ,A4-1754,.. C-1-- `n <174 37 . .
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(north,day,year)
Address of authorized person (number and street dry,state„and ZIP code) -