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ea, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
ii_%.,1. -•• •'7.ja FOR DEDUCTION FROM ASSESSED VALUATION
Y'`tj- State Form 43709(R11/6-09)
' Prescribed by Department of Laval Government Finance
File Mark
' INSTRUCTIONS: 7 r ;r_or i�•t
To be filed in person by mail with the County lo
or County Recorder of the county where the property is beat I F.j fled VI' t
(�•
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. gg 1 ; ne f a.. -editor
•2) Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months
before March 31 of each year the deduction is sought. •. County Recorder
I
See reverse side for additional instructions and qualifications.
Appfxant or contract buyer-see`.-r on reverse aide) A
I PAL 1 As A�.._i - ___-A / .
Taring District fCeynumber i legal desa,±V roo -DO4. 0d2 001 ) GIB seyrnAtcyjr
. b-I� `di1 ( ( Q(p -
Assessed value d real pronely as of Mortgage/Contract Indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the apparant the sole
Meth 1,current year =yew/
arrtem year date of aPPlication legal ar equitable rnmeR
No
If no,what is h-sl her exact share of interest? I �( If owned -^
If name on record is different than that of app&rant,indicate below:
1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract cener(number and meet,city state code) •
'/� �� � (\�� —
Name of assignee or other owner or holder of mortgage 'l f C,1 C1 `�-
Address of assignee(number and street,ray,state,and ZIP code)
Does applicant own Properly in any other If yes,what county? hat Taxi, I L\Z\DD-V�.!
county in Indiana?
El Yes
❑ No 1
m
COUNTY AUDITOR rA/1 I - —1 Ci� '
Deduction approved the amount of 1O-i� ?_Si)
20 20 20 20 S —
Signature of County Auditor County JJJJ
I/We certify under the penalty of perjury that the above and foregoing information is trt
owner I contract buyer of the aforementioned property on date application is filed.
Sg m(owner's hntl name) —
a pnran `Pt 1,12441.4.4(.1-1— _
nt dress of ap umber street,city, LP code)
S s . Io .D,.�.4Z6 —
Pesori authorized by duly exewted Power of Attorney or by 1 6-1.1-12-0.7
Address of authorized person (number and sheet,dry,state,and ZIP code) .