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} STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
FOR DEDUCTION FROM ASSESSED VALUATION �I
:0 1= State Form 43709(R11/6-09) {I {y
_ - Prescribed by Department of Loral Government Finance e ' i� rr(f
11LL J��LLL Ft a arks/
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INSTRUCTIONS: �,,p�etlto�m:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. OCT Fl v Cu 1 J
Filing Dates: 1) Real Property 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. n/ • n Recorder
See reverse side for additional instructions and qualificatIons. nIRSON COUNTY AUDITOR
Ap (owner or contact b^uy,er� -see '-• i• on reverse side)
Taxi District l Key number/legal description Record number Page number
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Assesses value of real property of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year Mandl 1.current year date of application legal or equitable owner?
If ho,what is his I her exact share of interest? if owned with sum e atria a D 0 spouse,suidkate with whom ❑ Yes -❑ No
1
If name on record is afferent than that of applicant,indicate below: Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
E "r F U
Address of mortgagee or contract seller(number and street,city.state,and ZIP code)
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Name of assignee or other owner or holder of mortgage
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Add� assignee(nu
of assignember and street,city,state,and ZIP code)
- Y�' £ ^' c a , - x - 10 1 . 9 98' fC.
Does applicant own property in any other If yes,what county? - What Taxing District? -I Has this deduction been requested on property
county in Indana? ❑ Yes ❑ No rrern YP- __❑ Yes ❑ No
I COUNTY AUDITOR
Deduction approved in the amount at D I_a 11'C1- N (90/.3
20 20 20 20 20, C;)f'Cj )\r0. (J /�)
Signature o County Auditor, 1 County I .•. ....•...
I 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 co, ,
owner/contract buyer of the aforementioned property on date application is filed.
(owner's hi name) bate(7M,day.year)
AFull resident address of appGai nt(n Der and sheet,city,sAr. and ZIP code)
r�S ,3S 6 . 3s D ) c-: nr,4 A- -rrJ 441 Lao
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 / Date(month,day,year)
Address of authored person (number and street,city,state,and ZIP code)
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