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. �; :� STATEMENT OF MORTGAGE OR CONTRACT INDE Tra fe}(y Township Year
CFOR DEDUCTION FROM ASSESSED VALUATIO
State Form 43709(R77/6-09)
Prescribed by Department of Local Government Finance
2014
INSTRUCTIONS: OE C g File Mark
To be tiled in person or by mad with the County Auditor or County Recorder of the county where the props 15 1.��: -.. Form mea with:
Fling Dates: 1) Real Properly.Must file during the year for which the deduction is sought t ;r m County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property:Must Me durin. L- , _rejoin 61 rt i ITOP
before March 31 of each year the deductions sought - O County Recorder
See reverse side for additional instructions and qualifications. G(g$ON CO
Applicant(owner or contact buyer-eak restrictions on verse side)
r ,1 m�.� R i- 0-41.o C 11J.«.o,21
Taxing District Key number/legal description Record number Page number
/O&M/ z & - /R' -2 (c_ /Oo ao / 775 6102.5 / 4/ y Sig-
Assessed value of real property as of yea Contract Indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the appinnt the sole
Marts 7;axle t year 1 aCine��nt yeas 1 date of aPP�tion legal of equitable come?
�/o_ o ❑ 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 is different than that of appf+cant.Indicate below Is the property in question:Annually Assessed
Real Property ❑Mnua lyAssessed
Motile Horne(IC 6-7.1-7)
Name of mortgagee or crt sellEfy
cct tss
Address of mortgagee or contract (number and street city,stato,and ZIP code)
Name of assignee or other owner or holder of nongage tit -
Address of assignee(number and street city,state,and ZIP code) , / E S h-7 ('- C-\-( P - -
Does applicant own property in any other It yes,what county? - 1 IS lA P e. C esled on property
county in Indiana?
❑ Yes ❑ No Yes ❑ No
Cot 114-LI 55)
Deduction approved in the amount of: -
20 20 20 20 20 20_ 20
Signature of County Auditor ' County Date(month,day,yew)
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
owner I contract buyer of the aforementioned property on date application is filed.
�Signaaue vmar5 fu0 name) Date(month,da,year)
Full msid of 73rd3 w �`85d 5 bra, M Pmt LJ 4/76 erg .
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Lon Date(month,day,year)
Address of authorized person (number and sheet,dry,state,and ZIP code) .