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STATEMENT OF MORTGAGE OR CONTRACT I b ociLNi unty Township Year
€.. 9A��
.��� : FOR DEDUCTION FROM ASSESSED VALUATIO
r State Form 43709(R111609) 1 1 `e;
Prewibed by Deportee of Lad Government Finance 1
j� ti -C' File Mark
INSTRUCTIONS: / 1 and, R Form filed with:
To be filed in person or by mai with the County Auditor or County Recorder of the county where t : • %0. y, \-�O
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought YI'(--1,^`` County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property Must file du',ti . EdeNt(12)months
before March 31 of each year the deduction is sought GO County Recorder
See reverse side for additional instructions and qualifications. ///999
• ./, iii �I( �L_ 9= �t- ! ., / Alf k 0
axong Key .description r . .. .number Page numbs
2eo- $ a4,- yin ood 8' 70o 9 /y /3 1
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appfcant the
March 1;current year March 1 wrTent date of appEcatlon legal or equitable owner?
4L,--/-754() ❑ Yes ❑ No
If no,what is his/her exact share of interest? I.'./—_- -,`/1—^^^[�^•kt than wince�ind/i att,,e1/w/�ithh wham
If name on record is(Efferent than that of applicant.Indicate below. I J_)(1 (A A . r y /' 7 -r - �A rtes 6-1.1-7)
�ee seller - /
M of mortgagee or dsWer(number and street uN.state,aM ZIP code) SCIVSI r 1 �lC��i cekisrPc- K
Name of assignee or other owner or holder of mortgage
•
as ii 750
Address of assignee(number and street city stare,and ZIP code) �r'� /�
Does applicant own property hi any other If yes,what county? • /4 Cie-1111 6t ,'C icaf L m property
county in Indiana? "1 t
❑ Yes ❑ No • a t rY' /fV°Y ❑ No
COUNT k1G-/ N
Deduction approved in the amount of: . ' ) 3 5 3
20 20 20 20 20
Signahre of County Auditor '
I/We certify under the penalty of per ury that the above and foregoing MI 'Indiana and
owner I contact buyer of the aforementioned property on date applicatior
Signature royilds
_ ..., .a /. sa . .
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7
Address of authorized person (number and street,city:state,and ZIP code)