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a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
' ' LS : FOR DEDUCTION FROM ASSESSED VALUATION
t State Form 43709 artm/6-0g) 1�
Presonbed by Deparurrerd d Lncd Government Roo
.
Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought J J 164 ugritOr
2)Mobile/Manufactured Homes not assessed as Real Property Must Me during the twelve(12)months
before March 31 of each year the deduction is sought County Recorder
See reverse '• for additional instructions and qualifications.
Appear (•. • or ovio-actb -r-see= ' on reverse side) L ...91 n a:12Wisrry AUDITOR
T.:.. ss.,'.. Key pybe/legal tl Record number Page number
' i2rxP-C v 1/4?- are/-do 0. .572- oo?b' opi .5.2,57
Assessed value areal property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
Marsh 1,anent year March 7.aurent year date of epph auon legal uitable Winer?
El Yes 0 N
If no,what is his/her exact share of interest? If awned with someone other than spouse,indicate with whom
If name on record is dr,°,erent than that of apprnant,Indicate below Is trye property in question:Annua%Assessed
`F l-',�l(Real Property 1:1 Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee comers Belle a r,]/r,
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,cry,state,and ZIP code) - -- -
Does applicant own property in any other If yes,what county? • Mat TaQ� f � ty
county in Indiana? ❑ Yes ❑ No - '—^'�'� No
COUNTY AUDIT( �Vll"``,- 3a3,
Deduction approved in the amount of: - �4 Sf ��
20 20 20 20 20 1RR1 20 20
Signature of County Auditor ' County Date(month,day,year)
I 1 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 1 contact buyer of the aforementioned property on date application is filed. .
nature(owners fire aame ' Date(month,day,year)
Full esldent address of applicant
S (number and street,ely, te,and ZIP code)
X 10 9 . {n 0 son S+. k rx-e n
,T X) 1-17C;?o
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(north,day,year)
Address of author iced person (number and street,city,state,and ZIP code)