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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear �
.__ , FOR DEDUCTION FROM ASSESSED VALUATION
� State Form 93709 (R71 / 6-09)
�' w�. Presaibed by Departmenl of Loral Govemment Frar�ce �
File Ma
WSTRUCTIONS: wn� -�IAf �� R �
To be filed in person or by mail with the CountyAudifor or Counry Recorder o! the county where the property is located. D J� 1 L U � Z �
Filing Dates: 1) Real PropeRy: Must file during the year /or which (he detluction is sought. Counry Auditor
2) Mo6de /Manulactured Hortres rrot assessed as Real Property Must file dunng the tweAre (12) months C`J,
6e(ore March 31 0/ each year the deduclion is saghG tY Rec°�de�
Seereverseside/oradddronelinstn¢' nsarrdqualfirations. GIBSON
MP�� a/�� bN'er - se an revzrse side
LL% -!TZ Li -
ri�g Distrid Key rum�Cer / kgal description R¢m�tl numMi Page numbu
- io- 6-iol - 000. 988_� � 597
Aaesse0 d 2al as d A1pry�g e/ Conbati i�ehteE�ress uMaiE as W Mortgage I Con� iMe6tedness unVaid a d Is Ihe aPP�I Ne sde
Mardi 1. yrar Mamh 1. artent year date af aPP�� kgal or equitade amM
It ro. what a his / �er erarl
If name qt reCO'tl is EiRUer
Name of rtnrtgagee w mntraG se9er
fddress of nnrc�a9ce w mntrea seAer (nunhu and strce; rdy, slate, aM
Name at assignee w other owner or hdder of morigaga
Atltlress of assgnce (number aM stree4 �: s+afe, enrl Z/P code)
epplkant ovm yoperty in any dher
h �� ma�?
❑ Yes ❑ No
iceon app�oved In Ne amount of.
20 20
SignaWee NCo�mbnuditor
��
I I We certi(V under �he
If yes,
Ifowned
i O � ❑ Yes ❑ No
sD�+�. �icate with �ham
�la theJ� °GenY in 9uesron: MnuaM Assessetl
�eal ProPeAY ❑ AnnuallY Asussed
Mobae fbrt�e QC 61.7 �
a�o� a.......
Dra�vcr NO............
5q1� .
Card NO . .....................
� ����,��
.....�n i � AUUROR
en re9uesteE m O�P�Y
❑ Yes ❑ No
20 _ 20 _ 20 _ . 20 _ 20 _
Caunry Dete (month. daY• 12a�
e above and foregoing infortnation is true and cortect aM �hat Ne applipnt is a resident of IrMiana and
�roperty on date application is filed.
Date (monfi. daY. Y��
/2 —Z�i�—iZ
ACtlress of autha'¢ed person (number arM sbee; cily, state, and LP tode)
�Y. Yea�
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