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STATEMENT OF MORTGAGE OR CONTRACT INDEBTED N t. Township Year
' ' FOR DEDUCTION FROM ASSESSED VALUATIONg"!
State Form 43709(R11/6-09)
Prescribed by Department of Local Government Finance
O 2013 File Mark
INSTRUCTIONS: NOV 1 7+ Form NS with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is I. -ted.
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. } -el I County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property:Must fie during \is. ;1 7jj'%Tt, s
before March 31 of each year the deduction is sought N COUNTY AUI ITOR County Recorder
See reverse side for additional instructions and qualifications. GIBSO
sit :r or contract buyer-fig .yym hct'ans on reverse site)
s .,
Taxing's' -'.,/ Key nu /legal description Record number Page number
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Assessed value of real property as of e/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
Mardi 1,current year ,current year date of application legal or equdtade owner?
❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
I
If name on record is different than that of applicant,indicate below Is the property in question:Annuaay Assessed
e RS Property ❑Annually Assessed
I "chile Home(IC 6-1.1-7)
Name of mortgagee or contract seller }
Address of mortgagee or contract seller(number and t.city,state.and ZIP code)
01.3
Name of assignee or other owner or holder of mortgage :••'
(�l:�\\'Cl 1 '�i"I
Address of assignee(number and street,city state.and ZIP code) v (((Y�CCC��///���///���^((('''///��r-//////���pppl��I111��, 11
Does applicant own property in any other If yes,what county? d 0. • I ..-men requested on property
county in Indiana? ❑ Yes ❑ No I Cll. I ._.Ica year? ❑ Yes
❑ No
I
COUNTY AUDITOR
Deduction approved in the amount of.
20 20 20 20 20 1 20 20
Signature of County Auditor County I 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. I
Sigpature(owner's boll name) Date(month,day.year)
�y � �lnir„„i”,
F resident address of applicant number and sheet,aty,state.and ZIP code)
X2r4 ii VA)d PIT .,�//I'd/l-7nKi Ill - -
Person authorized by`duly executed Power of Attorney dr by IC 6.1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city state,and ZIP code)
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