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STATEMENT OF MORTGAGE OR CONT$ACLLBS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
);(. State Four 43?09(R11/6-09) NOV 13 2313
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: -*law!,
,/, ilk 41:7 Porto filed with:
To be filed in person or by mail with the County Auditor or County Recorder of •r dry••r•1: I .,. :•i-. is located. �-,
Filing Dates: 1) Real Properly Must file during the year for which the( r .•' . ur I County Auditor
2)Mobile/Manufactured Homes not assessed as Real Properly Must file during the twelve(12)months /�"❑"
before March 31 of each year the deduction a sought County Recorder
See reverse side for additional instructions and qualifications.
7(owner or comma buyer- restrictions on reverse side))
Ic}CP-t° t /Jlm.r 1 lI r
7a Istria Key number/legal descripti/on ( Record number Page number
,�/r q C?<o-)f(s- 3G- 'Ya3• oOnJ8a 00 ( 6/3 5r3gf
Assessed valve of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/ indebtedness junpaid as of Is the applicant the sole 1,current Martyr current year March 1.current year date of application ❑ Yea O legal
/5i 96 5
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 apprrcent,indicate below. Is the property in question:Annually Assessed
eal Property ❑Armually Assessed
• I Mobile Home(IC 6-1.1-7)
Name rageselle
Address of mortgagee or contract seller(number and street,city:state,and ZIP code)
Name of assignee or other owner or holder of mortgage I
Address of assignee(number and street,city:state,and ZIP code) I - -
Does applicant own property in any other I If yes,what county? ' 1 D ca I y e(• ),�O..ry/`- m PrePat'7
county in Indiana? ❑ Yes ❑ No ;�!!�i1��,.�// •••.... ❑ No -
COUNTY. Card NO. ....583y .
Deduction approved in the amount of: I J• )/�•.• •••. .
Ir lO S. OO
20 20 20 20 20 20
I I
Signature of County Auditor •
County I Date(month,day,year)
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 and
�/owner/contract buyer of the aforementioned property on date application is filed-
f' 1 .Iffhlrt'L I Date(month,day,year)
``Full resident address of a 1 t(nummber and stieet Grp,stall,and—ZIPP—code) /
Person(0a 5 ICU Pole'of Attorney or by d hi: S C6,i_,p-0N -17634 I Date(month,day.y
Address of authorized person (number and street,city,state,and ZIP code)
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