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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(NG/6-09) xp�,' E��A�� I
•
Presmbed by Department of Local Government Finance �•} " i
INSTRUCTIONS: g .
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is lasted. Fay �e�1�[
Fifmg Dates: 1) Real Property.Must file during the year for which the deduction is sought JAN th VA Auditor
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the tweWe(12)months LLLJJJ
before March 31 of each year the deduction is sought 0 CCU Recorder
See reverse side for additional instructions and qualifications.
Apprwant
description Recall number Page number
044 - La orb- ( '/-JS- 3o3 -000. 3 a 7 - op eb`ed' ?o ) Y send
Assessed value of real of Mortgage/Contract indebtedness unpaid as of Mortgage/ ess unpaid as of Is the applicant the sale
Mardi 1:axrent year March 1,cement year date of ap s, legal a equitable owner?
� 6 LI 6 o ❑ 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 read a afferent than that of applicant indicate below Is the property in question:AnntmfyAssessed
❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee( _
Z-94:/-01—/�t
Address of mortgage or or contract seller(number and street city,state,and ZIP code) - - -
—
Name of assignee or other owner or holder of mortgage T� �/�/�
Address of assignee(number and street city std and LP cede
Drawer NO (-2c/C7
. JLa x42%
Does ty in Indint own property in any other ❑ No If yes,what county? What Taring Disbict7 n 11, 7 70. Q91-1
Doan m Indiana? C 1 5
❑ Yes ,
COUNTY AUDITOR
Deduction approved In the amount of: . '
20 20 20 20 20 20 20
Signs r. ' v County Date(month,day,year)
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!contract buyer of the aforementioned property on date application is filed. .
XSign urei(owners fug name) Date(month,day,year)
'u d" Z %//t./2
F ent address of a fuant(number and sheet city state, ZIP code)
�2..,J W. 4 i on 5F,, 0sklgrdC't I Std , y7/,t Q
Person authorized by duly executed Power of Attorney or by IC 6-14-12-0.7-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code) .