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t., STATEMENT OF MORTGAGE OR CONTRA TE S County Township Year
rrr}}}ai a4` FOR DEDUCTION FROM ASSESSED VALU
State Form 43709(R11/6-09) I
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: FEB 1.3 2014
Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.
FrTmg Dates: 1) Real Property Must file during the year for which the deduction is soyghG County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property M ' eNe(12)months
before March 31 of each year the deduction is sought County Recorder
GIBSOTNiOCO NTY AUDITOR
See reverse sider.,�4.additional instructions and qualifications.
App6canl(owner• ; - r, -,re,rse yl
D. , Key number/legal desc7/ptgn Record number Page number
,( 1t. .I I / 0 - 0 . 00 tod�-.rate ol real ... of Mort gage/Con ebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
Mandl 1,current year March I.current /O date of ap rfiatm legal or r
equitable owner?
❑ No
If no,what is his/her exact share of interest? J If owned with someone other than spouse.indicate with whom
If name on read is different than that of applicant.indicate below. Is the property in question:Annually Assessed
❑Real Papery ❑Annually Assessed
. Mobile Home(IC 61.1-7)
Name of mortgagee or contract seller :_/) 9 r ,
Address of mortgagee or contract seller(number and street,city,state.and` l/VPcoda)
Name of assignee or other owner or holder of rtortrvr-^-
•� � n
Andres:-'— ` _ n, ry/�D
Does a( �J N IN o.. "' •••••••• What Taxing Disb ct? Has this deduction been requested on property
armya Ara\�`el for current year ❑ Yes 0 No
canJ�5r7sOap10i�'O— .- )l1NTYAllorroR
Deduction pO.�r�r cud
20_ 20 20 20 20 20 20
Sig Ali / - I , / County Date(month,day,}ear)
/ ��•
I l 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.
J curer§fire Date(month,day,year)
�iSl7 'wt(sow.
resident address of apprrant(number and street.city,state a7P )
23/ V. /110/-4/ S7`, Oak/anA1 671y TN y76 60
Person authorized by duly executed Power of Money or by IC 6-1.1-12-0.7 Date(month,day,Year)
Address of authorized person (number and street,city:state,and ZIP code) .