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a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
FOR DEDUCTION FROM ASSESSED VALUATION ill.
State Form 43709(R11/6-09) !
'' Prescribed by Department of Local Government Anne ' r� I-:
File Mark` ;Pr
INSTRUCTIONS
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To be filed in person or by mail with the CountyAudifor or County Recorder of the county where the property is located. c[
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. • ❑ County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months 47 ■ Recorder
before March 31 of each year the deduction a sought G/ --11^4w4
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See reverse side for additional instructions and qualifications. OU TY A
App6gy(tar mrrtrd�n � tar 'wumrever atria)/ f /� _ U�fIOR
Record numb, Page number
Assessed value of reaof =lea,/ ntra indebtedness unpaid as of date of a�e/Contract indebtedness unpaid as of �a eqp u table owne?
March 1,summit year Antony ppC��/ //
//`�" / Cl U O ❑ Yes ❑ No
If no,what is his/her exact fIwe of interest? If ■
awned vrith someone other than Ran.,Indicate with whom
If name on record is different than that of appiant,indicate below: Is the property in question:Annually Assessed
Real Property ❑Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller X11 // 1 �r ��/I� /) l �`
Address of mortgagee or contract seller number and street,city,state,and ZIP code)s/`�f(f/�^/J�JI '
Name of assignee or other owner or holder of mortgage / / /) r�7 , it/�
Address of assignee(number and street,cry,state,and ZIP code) �/i G / /1/ /�`.•lf 2
Dces applicant own property in any other I If yes,what county? • I What Taxing District? _ I Has this deduction been requested on property
county in Indiana? ❑ yes ❑ No ' l Sr mutant YeaR ❑ Yes ❑ No •
Deduction approved in the amount of: t))
Drawer NO y
C Iry Vw,-c-vd `
20 20 —kl_ ra (� _ S 20 20
Card NO. vr�r1,..L., _
Signature of County Auditor —1 _r1 , 1 b _'�-- Date(month,day,year)
P J l
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
4 owner/contract buyer of the aforementioned property on date application is filed. --
4 Signs, 1(ov I! / Date(month,day,year)
1 � ./O R ,t(number (6 ZIP... (1 `// ^''/I// / °477/760
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 1/ -, Date(month,dal:yeah _ _ _
Address of authorized person (number and street ant state,and ZIP cede) -