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„�� STATEMENT OF MORTGAGE OR CONTRACT INDE 'Cgpnt� Township Year
&F d: FOR DEDUCTION FROM ASSESSED VALUATION I®P �', 9�/9
- t' State Form 43709(R11/6-09)
Prescribed by Department of Local Government Finance
INSTRUCTIONS:
JUN 2 4 2013 File Mark
To be filed in person or by mail with the County Auditor or County Recorder of the county where th- .mperty' I. Form filed with:
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought - �i Court Auditor
2)Mob de/Manufactured Homes not assessed as Real Properly Must file during ''''t ..p �r the b
before March31 of each year the deduction is sought GIBSON COU T AUDITO- County Recorder
See reverse side for additional instructions and qualifications.
AppeaRlowny or contract buyer-irWs on re site)
��t q
Taxug Key number/legal description G Record number Pagp�nummber
`/ Cc-C14/0 QG id f Mortgage o�7ebtedness unpaid as of Is the applicant the sole
AMari�1,anent year Marian 1,. -e.ntt year data of application legal or equitable owner?/ (/o 00a ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant indicate below: I perry in question:Annually Assessed
Real Property ❑Annually Assessed
• Motile Horne QC 6-1.1-7)
Name of lgagee or comma setter /c_if
Address of mortgagee or tract setter(number and street,city:state%end PP node)
--
Name of assignee or other owner or holder of mortgage IX '-7,�
-
Address of assignee(number and street city:state,and ZIP code) D l J
.................
Does applicant own property in any other If yes,what county? - What Taxis Drawer N O"'� ..
my in Indiana?
❑ Yes ❑ No No
_-)-_� ' <3 4 -/- /�
COUNTY AUDITOR Card NO. .n�
Deduction approved 4n the amount of /Oaf MI(J V
20 20 20 20 _ I 20 20
Signature of County Auditor 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 aforementioned property on date application is filed.
•• .(owner's AS name) w Date(month,day,year)
I
•
F resident address of applicant(number and sheet tray,state,and ZIP code)
>5n7 D6-1 ,Px9To.0.9- R.D 2A7-nKi4, sA) TD 47/7d6ie
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street dry.state and ZIP code)