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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun • • t,1111k, Year
It
FOR DEDUCTION FROM ASSESSED VALUATION y •.State Form 43709(R11/6-09) '
:?q'7 Prescribed by Department of Lod Government Finance
File
•
INSTRUCTIONS: I
NO 'Form rued with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.
Filing Dates: I) Real Pm perry:Must file during the year for which the deduction is sought. Elf ••� Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months ) •-�f)nlljjr
before March 31 of each year the deduction is sought. b
See reverse side for additional instructions and qualifications. GIBBON - - •TY
Art.... I(owner or mnoaa buyer emstrspogs/+n reverse side)/
T.• ;D' , Key number/legal d " tian Record number Page number
I -. • ' alc-l9- /9 - soy - oaf A85 - 0 - , � 20i,3 57 '7 C.,
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contact indebtedness'unpaid as of Is the applicant the sole
Mardi Ma 1.asrera year March 1,current 1 3 O D O data of appication ( legal or equitable owner?
❑ Yes ❑ No
If no,what is his her exact share of interest? y If owned with someone other than spouse,indicate with whom
If name on record is different than that of apps_L indicate below.
Is the property in question:Annually Assessed
` ❑Real Property ❑Annually Assessed
I Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seer(number and street,city,state,and ZIP code)
I Name of assignee or other owner or holder of mortgage , :�,._ .._ ..—__.. ///,
Address of "gnee(number and street d0:state,and LP c�)e) (/ /�/
Cr e�n> 7q/ l37yst Drawer NO v1
Does app want own property in any other If yes,what county? • What Tarring Dstric
county in Indiana? ❑ Yes ❑ No --�1l� /
Card \TO. ..5.. Q,,, _
COUNTY AUDITOR _
Deduction approved In the amount of:
—
20 20 20 20 20 1_ 20
Signature of County Auditor . County Date(month,day,year)
I/We/We certify nalty 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.
s(owner's'l0 +) � p�, Date(month,day year)
Full reside Ladd t(number a L and ZIP cod
r cN • $'OS f& (/7(at(x
Person authorized by duly executed Power of Attorney or by IC 6.11-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet dry,state,and ZIP code)