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S STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R11/609)
Prescribed by Department of Local Government Finance I „J fv1�
INSTRUCTIONS:
b be filed in person or by mail with the County Auditor or County Recorder of the county where the properly is bcat f3 9 Form a.,
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought G 9 `1�1J 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 - !�^�''n'��(—`'�'1^`I` CounCounty Recorder
See reverse side for additional instructions and qualifications.
' `
Applicant uler-+aer c0mrs e) C IDS ON (OU N I Y AUDITOR
UDITOR
, C 4 reverse }
Taxulg D' Key number/legal desaiplion Record numbs Page number
Gift . as -/g-[3 - you -"°°- 7 .t6 _ o al /3 .3A9/
Assessed value of real property as of Mortgage/Contraa'udebtedness unpaid as of Mortgage 1 Contract Indebtedness unpaid as of Is the apperant the sole
March 1,anent year March 1,current year date of application legal or equitable owner?
Io r O4/ ❑ Yes ❑ No
If no,what is ex
his/her act share of interest? r If owned with someone other than spouse,indicate with wham
If name on record is afferent than that of epeecant,Indicate below sled
Sled
Name of mortgagee or conpap Idle gib r r i//A�
Address of mortgagee our(/ccon- VVtract seller(number and city, te,and LP code) 7eA��fATGrA A
Name of assignee or other owner or holder of mortgage /7 Q �GJ-A
Add f assignee(number and sbeef,ray,state,and Z/t;code) /_ I l/f m K�� l�
Does applicant property in any other If yes,what county? • N lt, x/105461 'petty
county in Ind' ❑ No
Oyes ❑ No
COUNTY Al
Deduction approved In the amount of: /3—3025/
20 20 20 20
Sign= ofi�l.A.c l G
I/We certify under the penalty of perjury that the above and foregoing infonnat la and
owner/contract buyer of the aforementioned property on date application is file
1� Mname Han__
1�F add appl is (/ stated LP code)
/� h I ///r/) F-6- Opel 1x) Wif/r
Person authorized by duty executed Power af�Attorey or by IC 6-1.1-12-03 Date(north,day,year)
Address of authorized person (number and street city,state,and ZIP code) .