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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
E Co wear
It;q FOR DEDUCTION FROM ASSESSED VALUATION
:'fit State Form 43709(R11/6-09)
' Prescribed by Department of Lod Government Finance
INSTRUCTIONS:
NOV I
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. Form Bed with:
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought Co .. .... ..
2)Mobile I Manufactured Homes not assessed as Real Property.Must file during the twelve(12)months l 'grmj�,
before March 31 of each GIBSON CO, `TYA Recorder
year the deduction is sought a in
See reverse a for additional instructions and qualifications.
Appfra orcon/artbuyer/see restd�'gl� nreverse
On(, .., art lr[/le9 esayi �/ number Pa
rk 0 -%3 Vow 90/. Tit Al 0/o as %'a
Assessed value of real properly as of Mortgage/Contract indebtedness unpaid as of Mortgage l Cation indebtedness unpaid as of Is the applcant the sole
March 1:anva year March 1,current year date of appfimtion/O` 6� legal ❑ 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&decent than that of apolicrnt,Indicate below Is the roperty in question:AnnualyAssessed
eal Properly ❑Annually Assessed
• Motile Home(IC 61.1-7)
Name of mortgagee or contract seller
A1 i
Address of mortgagee or contract seller(number and et city,stain,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code) c.c� /02 _/' 0g/ie.,
Does applicant own property in any other If yes,what county? • What Tang Di strict? Has this deduction been requested on property
county in Indiana? ❑ Yes ❑ No for current year?
❑ Yes ❑ No
- -. _ - COUNTY AUDITOR
a
Drawer NO 0/4•••• 20 20 20 20
Si 411\99 99 County Date(month,day,year)
_._._.____.__.._._.agoing 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.
X Signature vner's tut name) Date(month,day,year)
P (ILO °Pi
FWreddent of applicant(number and street city,state,end ZIP code)
Hag C oo 3 Ockhnd CAI ,i.N 477(.00 ,
-
Person authorized by duly executed Power of Attorney or by IC 1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state.end ZIP code) .