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a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUA�TeI0��� ,'11,
f! State Foml 43709(R„/6-09) y
Presmbed by Depannrent of Local Government Fina ce p!A-{
File Mark
INSTRUCTIONS: ��y�C(f`� sq1 '(�'�
To be filed in person or by mad with the County Auditor or County Recorder of the cour¢ytwael4 the Qr jTy is located. Form feed with:
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file wring the twe 2}months
before March 31 of each year the deduction is sought. County Recorder
See reverse side for additional instructions and qua lifications. r=iBSO$ COUNTY AUDITOR
«......fie see d 1c-n- to
':ring Key number/legal non Recd nu Page n
• a�q o - la-bS- 3oo-coo.aW-oaC7 `� a
Assessed value of real property as a tract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the appriant the sole
March,:current year March l py�rh 0 CYO date of appfiration �N ❑ Yes ❑ oN
If no,what is his/her exact share of Interest? ®1 C/� If owned with someone other than spouse,indicate with whom
If name on ream is dC.erent than that of applicant.Indicate beow. Is the property in question:Amway Assessed
❑Real Property ❑Annually Assessed
. (('�� Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller , / n
(number Address of mortgagee or Contract seller( ber 434/kiwis.,street,city state,and ZIP code)
— man.ra scions or oth rwwner or holder of m/ortgage
. Drawer NO Q9`
aunty? •� What Taring District? Has current s deduction been requested on property
y ❑ Yes ❑ No
Card NO. 7 .
COUNTY AUDITOR
20 20 20 2020 20 20
)2fr. eitk
Signature of tar / � County Date(7 day d/
I/ e 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 afore entioned p toperty on date application is filed.
Signatu hg 1 Date(month,day,year)
�ss °fix
ent/a�ddQQress of a � sI/lr(e�eL sfaPe,and ZIP code)•
Person
910 69, dEez 1t�KQf 1\ by IC 6-f 1-f2 .7 \ ��`O�0 Date(month,day,year)
Address of authorized per son (number and street city,state,and ZIP code) .
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