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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
.ift.a.:: FOR DEDUCTION FROM ASSESSED VALUATION
V:411S.,M;E1 State Form 43709(R11 16-09)
--IFT 'FL. E
N----:=> Presaibed by Department of Local Government Finance
INSTRUCTIONS:
Forrn filed with:
'Th be filed in person or by mail with the County Auditor or County Recorder of the county where the properly is located.
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought.
OI8 CO
I so:Eel: oug3 Auditor
1 • TAY AUDITOR
2) Mobile I Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months
before March 31 of each year the deduction is sought
1 , El County Recorder
See reverse side for additional instructions a • qualifications. ,!VT"Wing;
Appbcaidirriwner or contract 7 see -- 4, on mifide) t/61 0
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°"--- illegal d 'ptien Ftecord number laig/number
KeYt i-a-/‘ - OW- (10/ 2d d'" Ody 076/J 393
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••••,.....,...value of real property as of Moiler co/Contrentra el indebtedness unpaid as of IdWaitretgora:Don...indebtednesi Unpaid as of Is the ppftcant the sole
• 1 legal or equitable owner?
l‘t ODD Eyes ID No
If no,what Is his/her exact share of interest? If owned with sorneo -other• .n spouse,indicate with whom
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If name on record is different than that of applicant,indicate below: Is prOperty in question:Annually Assessed
Real Property 0 Annually Assessed
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Motile Home(IC 6-1.1-T)
Name of mortgagee or contract seller
iillief I
Address of mortgagee or contract setter(number a •street ,.state.an7kIP e)
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Name of assignee or other owner or holder of mortgage
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Address of assignee(number and street cif%sha and ZIP code) (7,27, vx a_ /2/05-z, ,, 37
. /O- -/6 7/. 0 d 7,9d
Does applicant own property in any other If yes,what county? What Taxing District? Has thiededuction been requested on property
county in Indiana? for current year?
0 Yes 0 No I 0 Yes 0 No
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PIrP6 -3 --Pja ( C COUNTY AUDITOR I
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tet2,0Ck? I I
/ .5— 43(11/45 / I
I County 1 Date(month,day,year)
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....,,itt land foregoing information is true and correct and that the 4plicant is a resident of Indiana and
owner/contract buye-r of the aforementioned property on date application is filed. I
nature Zit fug Date(month,day,year)
lAin retident address of appricantpiumber a city,state,aril ZIP code) .
1A-M-RteffilireW 1 e 4 •_ , j44 ..5777D7,-- LA/ f-,/7413 r
Person authorized by duly executed Power of Attorney or by IC 6-1.1-1 2-0:7 1 Date(month,day,yea.)
Address of authorized person (number and street,cay.state.and ZIP code)
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