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a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS [:r .i�7�I�1�aF�y�j 1� ear B
rho; FOR DEDUCTION FROM ASSESSED VALUATION
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State Farm 039(R11/fa09)
Prescribed by 70Department o(loual Government Finance
. File Mark
INSTRUCTIONS: .
To be Ned in person or by mail with the County Auditor or County Recorder of the county where the property is located.
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Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. GIG SO Z'
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months 'O •'' ' H U DI TO R
before March 31 of each year the deduction is sought. - ❑ County Recorder
See reverse for additional instructions and quail lions. n
AP 1 / oopirarl / 'c• u on re side)4.n // /
?District C/fy//, Key number/legal description �r-4 iClXLsf'i r Record rnun P
� iURt.d ea Og. 3 0 -Ao/- ate /75-C a0GK 7
Assessed value of real properly as of fMoe rtgag /Contract Indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of is the appli ant the sole
Marts 1;omeM year a 1,wren year date of appgn/^� legal a equitable comer)
/y ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,Indicate with whom
If name on record is different than that of applicant,indicate below: H property in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller _ 6&E „Jy`
Address of mortgagee or contract seller(number and sweet,city.state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,c3):slate,and ZIP code) /
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Does a( _.____�__.,,n„, AIf.yes,what county? • What Taxing Di strict? Has this deduction been requested on property
county t for current year?
Met t TOP, 8�( 1Q El Yes El No
s;Lafoe€4 S COUNTY AUDITOR
Deduct
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2 20 20 - 20 20
Signature of County Auditor - • County Date(month,day,year)
I 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
//.tract buyer of the aforementioned property on date application is filed. .
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,...CAA full names) . Date(month,day,year)
As of / rt( be l �!
AAAl resident address of applicant�(numberand street cry,state,and ZIP code) , ! 1/419
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Person authorized by duly executed Power of Attorney or by IC 61.1-12-0.7 I Date(moth,day.Year)
Address of authorized person (number and street,city,state,and ZIP code)
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