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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION •
. � -. State From 43709(R11/6-09) ', i
��tq--'! Presmbed by Department of local Government Finance �• _•
*Tit ..
INSTRUCTIONS: , .
To be filed in person or by mail with the x�m.
Z;duatyAuditor or County Recorder of the county where the property is located. )/��CC
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought Coaiyl$uditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months
before March 31 of each year the deduction is sought .�/ ❑ unty Recorder
See reverse side ova instructions andqualifications. GIB$pNCnum,-
buyer- AUDITOR
T Key //legal d tion Record mum Page number
° ,f2z� ��(/L_/9-:-/r-,50/- 000 . 310 -({�17 I I/5X
Pressed value of real as I Mortgage I Contras indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the aPpi�nt the sole
Martlr 1:aurem rear I Marti 1,anent year date of apP j �1 �1 legal or equitable the owner?sole
o'd (� alt/ ❑ Yes ❑ No
If no,what is his/her exact of int rest? If owned with someone other than spouse,indicate vath whom
If name on record a different than that of applicant,indicate below. Is property in question:Annually Assessed
Real Property ❑Annually Assessed
Ain yJf� j /��t/� Motile Home(IC 61.1-7)
Name of mortgagee a contract seller /i �_2 76Ce Virf:�yteae Address of mortgagee or contract seller(n and street,ciy state,a and ZIP cod /
Name of assignee or other owner or holder of mortgage JJJ
Address of assignee(number and sheet,city,uatn,and ZIP code) 7 �t 1 / , c2
• Does applicant own property in any other d yes,what county? • What Taxing District? n�this uction been req/O/,1(uestedf/Kon property
❑ yes ❑ No ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved In the amount of •
20 20 20 20 20 20 20
Signature of County Auditor A 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•.ntract buyer of the . . - •-ntioned property on date application is filed.
FW, cot (number.., e.-q Wy,state,and JZlP�COde) /
illitiC Person authorized by duly exewted Power of Attorney or by IC 6-1-1-12-0.7 , C--to(rrerdh,day;year)
Address of authorized person (number and sheet,oily:state,end ZIP code) •