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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun i
Co, FOR DEDUCTION FROM ASSESSED VALUATION
;te State Form 43709(R11/6-09)
Prescribed by Department of Local Government Finance
File ark
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor or County Recorder of the county where the property is located. F „ —Wilt(
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. 01680 O $ v��'D ITOR
)r
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 • County Recorder
See reverse side for additional instructions and qualifications.
ApprcanL(awwnne rorr gtract t buyer-see restrictions on reverse scie) number Taxing District
...M—.)1 numbs/legal d Record number age���j
� � a` - 19- log - 3or)- , b1S -61_,. abo
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as o e 1 Contact indebtedness unpaid as of Is the applicant the sole
Math 1,anent year March 1.aiment year N. date of application legal a rtable owner?
` r Sfl o - es El No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with wham
If name on record Is different than that of applicant,indicate below. Is the property in question:Annually Assessed
deal Property ❑Mobile A�sses sssed6-,.,-7)
e of mortgagee or contract seller
Ca �f) S --- --
Add of mortgagee or contract seller(number and street,Cr!)
•
Nae of assignee or other owner or folder of mortgage /.)O. ..
Drawer
m
Address of assignee(number and steel,sty,state,and ZIP aid Le a........... f 0 E
Card NO. . .....u...
Does applicant own property in any other If yes.wd .duction been requested on property 1
county in Indiana? for current f..�s
Vl'es ❑ No I I 6d/Yes ❑ No
COUNTY AUDITOR r
Deduction approved hi the amount at - .
20 20 20 20 20_ 20 20
Signature of County Aueda - 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.
Signatu owners fill name) Date(month,day,year)
LP y 11\/ PenloNs
Fug resident address of applicant(number and street oily,state,and ZIP code)
YP lot, y S ► 7s E fe►z-r61-biludi1 ) 1E7 C, Ye
Person 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 and.sheet,city,state,and ZIP code) .