Mortgage_Hart (2) ;
STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
.•• State Form 43709(R11/6-09)
Presm'bed by Department of Local Government Finance
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INSTRUCTIONS:
To be filed in person or by mad with the County Auditor or County Recorder of the county where the property is I F
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought
2)Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months p 8 �-7� County Auditor
before March 31 of each year the deduction is sought - AP LJCU aunty Recorder
See revers side for additional instructions and qualifications-
Appbcen -rot contract buyer-see - reversesid -
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1 Key Orpnber / 'I/'',�/ / /9 / 'oQ1 ` V/o/2 P�n"' /
.of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the appfirant the sole
March 1,current year March 1,anent year date of application legal or equitable owner?
10?/ [ ❑ Yes 0 N
If no,what Is his/her exact share of interest? If owned with someone other than souse,indicate with whom
If name on record is different than that of applicant,indicate below: property in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1-1-7)
Name of mortgagee or contrail seller
Oa.ie_i fj1/
Address of mortgagee or contract surer(number and steel,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,c$t state,and ZIP axle)
201-aCW Does applicant own property in any other If yes,what county? What T District?? Has this deduction been requested on property
county in Indiana? El yes El No for current year?
❑ Yes ❑ No•
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor • County — I Date(month,day,year)
I I We certify under the penalty of perjury that the above and foregoing information is true and correc ''--__.
owner/
contract buyer of the aforementioned property on date application is filed. I r I A —
-( Signature owner's full
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Full resident ress of appGcont(number and street,ri(y state,and ZIP code) Lg/-Zy G
79751 S.4 '/1'6- I N- For+ 8cc .-c& irz /!7' rile" � �)'y
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0-7 /\„/ -6_ Cj
Address of authorized person (number and street,city,state,and ZIP code)