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S STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Thip Year
FOR DEDUCTION FROM ASSESSED VALUATION State Formby Department(rtment 09) /
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the ty ere the pmperty1rs�located.
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. N/ 1 uu 44
2) Mobile/Manufactured Homes not assessed as Real Property Must Re tit l me twelve(12)months aunty Auditor
before March 31 of each year the deduction is sought County Recorder
See reverse side for additional instructions and qualifications.
Applicant( dbuyer-seeres oionson rev� e) ` GIBS C'p11N.�Y AUDITOR
Q / She
Taxing Disoi Key number/legal desolation number Page number
Taxing 2/O-/9- /4 - zo3 -cc / . Z25-eaL n ( 3 (0.S
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Cantact indebtedness unpaid as of Is the app�the sole
March 1,anent year Mardi ,anent year date of aPPlicetion legal or equitable owner?
43 ed 00O ❑ yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with wham
If name on record'different than that of applicant,indicate below.. Is the property in question:Annually Assessed
Weal Property ❑Annually Assessed
Mobile Home(IC 61.1-T)
Name of mortgagee or contract seller /.5-7
/ty,
Address of mortgagee or contract seller(number and street cit sar:e code) .
Name of assignee or other owner or holder of mortgage
-
Address of assignee(number and street dry,state,and ZIP code) - _ — _____________
11 tetVailL39 0. Sege,
Does apples own property in any other If yes,what county? , What T �y y
❑ Yes ❑ No Drawer NO orb LS No
couNTYnuon Card NO. 5 3105
Deduction approved in the amount of:
20 20_ • 20 1 20
I I I
Signature of County Auditor County Date(month,day,year)
I/We certify unde • e pen of pe"ury• the a•• - and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/con. ..r• t't - . - en• Orly on date application is filed.
S re(o .../ , �� Data(month,day,year)
Full - t address of appaStri number and street,ary,state,and ZIP code)
`]c 7f p S u s No '-/1 r 3ceNc(+ ,rAl 17&MY
Person authorized by duly executed Power of Aftfirney or by IC 6-1.1-12-0.7 I Data(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)