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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
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FOR DEDUCTION FROM ASSESSED VALUATION
� State Fwm 93709IR71 / 609)
, � Presmbe0 hy �epartmenl of Laal Govemmerrt Fu�anca
ie
wsrRUCnoNS:
b 6e filed in person or by mail with fhe CountyAUditor or Counry Remrder o7 Me counry where the property is located. F!
Fitirg Dates: 7) Real Property. Musf fi!e during the year Por which the deduction is soughL
2J Mo6de / ManWadured Homes rat assessed as Real Property Must file dunng Me lweNe (12J rtronths C.
before Ma�ch 31 of each year the Ceduction is sought.
See reverse side for adtlitionel instruclions arrd qualrfications. G IBSON
App6qpt(owrre�aroonbartbuyer-seeresviclionsmreversevde) , ..
�
Counry Auditor
�nty Recorder
Key rum�her l iegal desaiption �/ Remrd rwmbPi Page
a�-/l-/�f- 3�0• 000. 35a-o 2-D io (��
s ol "- ortg ge/ Contraa 4Mnbtedness unpaid az of Mortgage / Contract indebtedness �mpaid as d is the apd�l ihe sde
MamJ�at. a�rtent year date of epplxation legal w equitade o�
�� �. Q � (� ❑ Yes ❑ No
mmro� ot� ttan spouse. h�te wtlh hiam
�wr�e on recortl a Eifre2nt Nan Nat of aPP��t IMipte below.
r�lame of rtnrtgagee « m�aaa sener
C S. �.
Addres W rt�or[ga9ee or wntraU sWer (number and streaf, cdy, sbta, aM LP mde)
Name of assignea or oitml owner w halder of mMgage
MEress ot a55ignee number aM stree4 mY, sbfe, entl ZIP cotle)
�T sw l- a-� �a.so f+ L
Does a�i�nl wm popeM1y in any dhg It ycs. wha[ tounty7 What Tarirg Distr'uY?
couNy m Intliana?
❑ Yes ❑ No
..__.--'+•�: MnuaM Assessed
Dra�ver i\i0.. ��,�..�,
Card NO. ...�.��.�.......
� alo�(�, �
Has Uris OeCUCtia� been re9uesteE on p�operly
��� ❑ Yes ❑ No
COUNTYAUDROR
D�uction aOD�� � � amount of:
20 _ 2b _ 20 _ 20 _ 20 20 _ 20 _
Sgra4ue d Counb Aud'rtw Caunry Date pmith. daY• Y��1 _
e.T
1/ We certify urWer Ne penalry ot perjury the above a regoing infortnalion is true and cortect and that the applicant is a resident of Indiana arM
amer I mntract buyer of the atrneme � property on te application is filed.
� Slgna6ve ( Ys hA name) � Date (nmfi. daY• Yaa�
�A Rsident adE o( a rant (num4er antl sbaet, �, sta . ZIP ootle)
i s as� �v � . �7
Pe�snn auNwtred by O�iy exewted Parer W Y a M IC 61.1-12-0.7 Date (rtmN. tlay, yea�
Address of autha'¢ed person (numDerand sbeef, ciry, sbfa, aM ZIP mtle) .