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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Court Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R71/6-09) v-
°� Presaibed by Department of Local Government Finance p )-
6Ap �. + File Mark
INSTRUCTIONS:
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year forkyOipt4the deduction is sought. •
Must be filed with the County Auditor or County Recorder of the countA2 reeth9p•.;$4y is located ❑ County Auditor
on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2)Mobile/Manufactured Homes not assessed as Real Property:Must fif9j-�Lvith the County Auditor of the
county where the property is located during the twelve(12)months Marc 1 • lryear the
deduction is sought. GIBBON
See reverse side for additional instructions and qualifications. C OUNTX`A UDITO P
Ap ' nt(owner or contract buyer-see restrictions on reverse side) t
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t C�AGi 4 V I L4ors° 1 G1n vv.1 Ike:
Taxing District Key num /legal description Record in' r Pa umber
9 ra&- 3-91 (0 - Vco-001. �Ceo- o2 `{ I � �7/lP
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Math 1,current year March 1,current year date of application .' legal or equitable owner?
2l
Ls
2A "J 1d1 Yes El No
II no,what is his I her exact share of interest? If owned with someone other than spouse.indicate with whom :J
If name on record is different than that of applicant,indicate below: ) Is th perry in question:Annually Assessed
-- Real Property ❑Annually Assessed
Mobde Home(IC 6-1.1-7)
Name of mortgagee or contract seller .
K-,r k54-de. MO 4c a 5i Le..J:•.c LI_C_
Address of mortgagee or contract se (number and street,city,state,a ZIP e)
co l Cross o h.�-1< "hk-,A Eva -s.i.\L r' Y�7IJ
Name of assignee or other owner or er of mortgage
Address of assignee(number and street,city state,and ZIP code)
Does applicant own property in ny other If yes,what county? What Taxing District? Has this deduction been requested on property
county in Indiana? for current year?
Yes ❑ No ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
. 20 20 20_ 20 20_ 20 20
Signature of County Auditor County 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 I contract buyer of the aforementioned property on date application is filed.
I Signaln(e(o�vrre s7 a name) n n Date(month,day year) .
Full relident a ess of ap nZ(number and street.city state.and ZIP e /
U7 Li? `l Warrc�4an ?2c). /Ja4 s44e)+ r' - Y7G3°1
Person authorized by duly executed Power of Attorney 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)