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nA STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count Township vear
:i_ _: FOR DEDUCTION FROM ASSESSED VALUATION /��
a� �' State Fwm 43709 (R71 / 6-09) � ���� ptcJl �
�����1• Presaibed by Department of Lacal Govemment Finance
iTRUCTIONS: ' File Ma�k
To 6e filed in person or by mail. Fwm filed vnth:
Filing Dafes: iJ Real Property: Must be crompleted and dated in the calendar year lor which the deduction is soughL � County Auditor
Must be filed with the CountyAUditor oi County Recorder o71he couniy where the propert
on o� before January 5 o7fhe immediately succeeding ca/endar yeai. �� ouniy Recarder
2J Mobile /Manu7actured Homes not assessed as Real Property: Must file with fhe CounryA it r of��he j
counry where the property is located dunnq the tweNe (72) months before March 37 of e yeact�e��
deduclion is sought. , -
See reverse side !or additional instructions and quali(cations. Or w
Appliaep� (Qwne� or contract buyer - see r@sLiclions on reverse siEe) �T�^
�� -1 ' v ' / —
property as of Mortgage / ConVact indel
^� Ma�ch� cunent year
I1
f no, what is Itis / her exact s�are of interesi?
tl name on record is CiYerent than Nat ol appticant, indicate bebw:
Naygcf mongagee or contrad seAer
�n� �I�e, �i��c� Q Inc
AOd u tmortgageewconVaGSeOer num6e�antlsbeet,uty,s
� Z°J �.�il�t�� �I V2.� QiIG� �� �
Name of assi9nre w oJier owner or hdCer oi mortga9e
ACtlress ol assignee (number and sireef, rity, sfate, anC ZlPcotle)
applitant own property in any other
y in InEiana?
n Yes
�G7
tl yes, what
with someone
NTat Taz�ng
iitable amer?
Yes ❑ No
than spouse, indiwte xi� whom
Is ihe properry in question: Annualty AsusseE
� Real Property ❑ MnuallyASSessed
Mobile Home (IC 6-1.
COUNTY AUDITOR
Deduction approved in ihe amount ot:
20 20 _ 20 _ 20 _ 20 20 _ 20
Signature of CounryAUAear Counry Date (rtronlh, day, year)
I/ We certify under Ne penalry of perjury that ihe above and toregoing intormatlon is we and cortect and that the applicant is a resident of Indiana and
owner I conVacl buyer of the aforemenlioned property on date application is fiied.
�griamre fs ( name) .� Oate (manM, day, yeaq
� h�
FuA rgsitlent a ress appliwnl (� mper antl street, cit lafe, and Z/ o0ej � -
� (A � 7 �
Person auNOrized by d zecuteC Power af Mwney or by IC F7.142-0J Date (month. Cay, year)
Addressolauthorizedperson (numberantlsfreef,dry,stale,a�MZlPcode)