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STATEMENT OF MORTGAGE OR CO T��NGG ' .n • r SS County Township Year
r FOR DEDUCTION FROM ASSESSED l TS6N
g_ _G-.
State Fors 43709(R11/6-09) 'Zp13
Presoibed by Department of Local Government Finance
3‘_w_ 9 File Mark
INSTRUCTIONS: el
To be filed in person or by marl with the County Auditor or County Recorder of th i••un a-.'aYr r, Q(p�gyitls located. Form fled
Filing Dates: 1) Real Property Must fife during the year for which the deducti• 1 .rR TY pct V'' - ❑ County Auditor
2) Mobile/Manufactured Homes not assessed as Real Propellrs •, t h. • nng the twelve(12)months
before March 31 of each year the deduction is sought.GIBSS ❑ County Recorder
See reverse side for additional instructions and qualifications. ////��
Ap.11 s(. • orobnbacta �7i/ reverse :. L J
Asa IS .._..IiI
T%' Key number/legal description Record number Page number
�rj i�o7 �o/�, iyl�(3 -oaf 3 . 3i6
Assessed value of real property as of Mortgage/Contract indebtedn unpaid as of Mortgage Contract indebtedness unpaid as of Is the applicant the sole
Marts 1,asters year March 1 data of apt 11011 legal or aguilade rrarreYl
(CCU(( ❑ 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: Is the property in question:Annually Assessed
Property ❑ArmualyAssessrd
Mobie Home(1C 6-1.1-7)
Name of mortgagee or contract seller /5
Address of mortgagee or contract seller(numbersbee4 city,state,and ZIP code) -
Name of assignee or other owner or holder of mortgage r\I� V_r'`
Address of assignee(number and street,city,state,and ZIP code) L.) r �"' 0u -
BRA
Does applicant own property in any other If yes,what county? • tested on property
county in India? ❑ Yes ❑ No /\-3 ■33I D I Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount at
20 20 20 20 20 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/contract buyer of the aforementioned property on date application is filed.
Signature(owners bull name) r( Date(month,day,year)
Fua ent ad res.'s-Of of applicant(number and street city,state,and ZIP code)
32/0 we.y S�da•.f& sf /P,e.rr-4a+1, /1f/ 47L 7D
Person authorized by duty exear Power of Attorney or by IC 6-1.1-12-07 Date(month,day,year)
Address of authorized person (number and sheet city,state,and ZIP code) .