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a STATEMENT OF MORTGAGE OR CONTRA TE County Township Year
r:�
FOR DEDUCTION FROM ASSESSED VALUI
' ',� Sae Form 43709(H„/ -09) FEB 11 Zp15
' Prescribed by DeparNreN of Loral Government Finance
File Mark
INSTRUCTIONS: -.1 .
lb be filed in person or by mail with the County Auditor or County Recorder of the coon .t„ ;•.11''-mm� i,o�'d d. Farts meal with:
Filing Dates: 1) Real Properly:Must file during the year for which the deduction is so r i(.CoUN ❑ County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property.,j..5:;' S unng the twelve(12)months
before March 31 of each year the deduction is sought ❑ County Recorder
See reverse side for additional instructions and qualifications.
•...¢ant(owner oir rsree
1 C 1 1 1 1 l �..Jel ti`r 1
Tari . . Key n miber/legal desahp' Record number Page number
� ' 109 ► ,- - a�� ► 4 ��a /y 67,7d
Assessed value dreal property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the appErarrt the sole
March 1;current year Mardi 1, nt year date of application legal or equitable owner?
//OG6 ❑ Yes ❑ No
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 afferent than that of applicant indicate below Is the property in question:Annually Assessed
*'}Real Property ❑Annually Assessed
J°' Mobile Home(IC 6-1.1-7)
Name of mortgagee or contact 'ter
Address of mortgagee or contra /seller. (n a�city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,slate,and ZIP code)
Does applicant own property in any other If yes,what county? - I What Taxing Mast? Has this deduction been requested on property
❑ yes ❑ No I N...__..—.,
Yes 0 N
t PtC/thitkLi an41 /n
Deduction approved in the amount of • /t
20 20 20 (CJ 20
• /4 O
Signature of County Auditor ' 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
own I contract buyer of the aforementioned property on date application is filed.
Sig (owner's name) Date(month,day,year)
/Full ant address of applicant(number and street,city,sta�tye,and ZIP code) `�
log. L✓. u.✓4rc/LrrC �� /JC:}l 7 ) Cl �G/l �c . /�C L ✓ % 7ob
Person authcsized by duly exeated Power of Attorney or by IC 6-1.1-12-0.7 ' Date(month,day,year)
Address of authorized person (number and street dry,state,and ZIP code) .