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STATEMENT OF MORTGAGE OR CONTRACT IND County Township I Year I
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FOR DEDUCTION FROM ASSESSED VALUATION
AY 2 4 2013
[ 1.-1.5. State Form 43709(R71/6-09) M
Prescribed by Department of Lod Government Finance
File Mark
INSTRUCTIONS: Form filed wrch.
To be filed in person or by mail with the County Auditor or County RecorderG4®6 ewe enmity C)5Wated.
Filing Dates: 1) Real Poperty:Must file during the year for which the deduction is sought. County Auditor
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
See reverse side for additional instructions and qualifications.
Applicant(owner• .. pact buyer-see restrictions on re •ma side) ` isi
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Key , 1-3 1-30o-coq:3 a0-0 a/ `t, _313
Assessed valued real.ff.peny, as of Mortgaye�/Contra indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Mardi 1,arrest year . MarMj�v jrenn 0 O date of application legal or equitable O
�}l Yes
If no,what is his/her exact share of interest? I
If owned wide someone other than spouse,indicate with whom
If name on record is different than that of applicant indicate below: Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
Mobile Home(1C 6-1.1-7)
Name of mortgagee or contract seller E. /J`J-
,
Address of mortgagee or contract seller(number and street city,state.and ZIP code))`f�
Name of assignee or other owner or holder of mortgage
�y U / E R y ounty? • What Taxing District? Has this deduction been requested on property -
1 for current year? ❑ yes ❑ No •
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/3 �,3/� COUNTY AUDROR
20 I 20 1 20 20 20 20 20
Signature of Coup OA^•imr 7 O `,1 n County Date(month,day,year)•
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the afore entioned property on date application is filed.
.. .nature(owners,• na / Date(month,day,year)
�--:'Are J .I/.. . . et 47 ��j
• ••--�d appfcant(/wmberS '_t om Ct 47 c' 4 &t2e6S
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street ay,state,and ZIP code) .