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a. . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Simmownship Year
FOR DEDUCTION)FROM ASSESSED VALUATION
'�*t� State Farm 437119(R71
Prescribed by Department of Load Government Finance qg
INSTRUC77ONS: �(. eta D
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. - hY
Filing Dates: 1) Real Property Must Me during the year for which the deduction is sought. ❑ County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property:Must Me during the twelve(12)months 7��
before March 31 of each year the deduction is sought - �U�CJI CLgatilitecorder
See reverse side for additional instructions and qualifications.
Ape;�an�ts caner or contract buyer-see restrictions reverse side) 'n
/`S/C /� /J� GIBBON CO(7N'T q' r ��r
Ta • District �J Key number/legal desaW' Record mimbet 'j PA9�1fJr:5tlMs
GJa el 40 8 - 007 00 2. 3 I, - 0 /8 toi3I 2- 885--
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applcant the sole
Marts 1,current year March 1,current year date of application legal or equitable owner?
l 5. Q O O ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than space,indicate with whom
If name on record is different than that of applicant.indicate below. Is the property in question:Annually Assessed
❑Real Property El ArmuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract serA
eu /1 r
Address of mortgagee or_contract seller(number and street city,safe.and ZIP code)
Name of assignee or otf.
Address of assignee(nu 47 CI) gicj
Air 0 el
Does applicant oven pro, �• _ :en requested on .I-
county in Indiana? yi
rW proPeny_f T ❑ Yes ❑ No`` r Deduction approved In I 7V J
.sr 20 A _ 20
Signs of County Au 8 rn. m,day year)
CO
I/We certify undo a resident of Indiana and
owner •ntract b
+h hr0 nth,day.year)
Fuqll resident ad.y—,e,/of apprcent(rum and-�a -ate,and ZIP code)
oC/ lit) /f:o/ -A - //17 57766 lP
Person authorized by duly executed Power of Attorney or by IC 6-1.e-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code) •