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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Court Township Year
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FOR DEDUCTION FROM ASSESSED VALUATION
• i: ;,, State Farm 43709 Department nt of t
P2srnbed by Departmerd al Lnol Government Finance File Mark
INSTRUCTIONS: • - .
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To be fled in person or by mail with the County Auditor or County Recorder of the county where the property is located.
Filing Dates: 1) Real Properly:Must file during the year for which the deduction is sought 9 County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months -
before March 31 of each year the deduction is sought I �jwr• . '°order
See reverse side for additional instructions and qualifications. GIBSO ' : •UDITOR
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�... contract b� e verse eL�,' 9i' / /1%-L J
Key '///os!d tion
number Page n
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J6121—E9o..v—?2-1010 air 0 '
Assessed value of real property as of Mortgage/Contract Indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the t the sale
March 1;current year March 1,cement year date of appGratioy legal or equitable owner?
��[j/•y 66 ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other spouse,indicate with whom
If name on record is different than that of applicant indite below: Is property in question:Annually Assessed
Real Property ❑Mobile Annually Assessed
Se Mobile Home(IC 6-1.1-7)
Name of mortgagee o contract seller /
J1 dYtA
Address of mortgagee or contract seller(number and sae 4 9 and ZIP code) '
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street aTy,state,and LP code) /
g ®z 7Zie,XX ead f )i 91.3
_. -t xxrniy.+ What Taxing District? Has this deduction been
requested on property
for current year?
3 _tC3 — k'rv..Se ❑ yes 0 N
Sryro_X S • Vs'b5e
COUNTY AUDITOR
2Q. ‘0b.s Qov.-
S- l8- l2 43v(400 20 20 20 20
County Date(month,day,year)
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.
SI -e(owner's/ggnamet Date(month,day,year)
/ Full resident address of t(number and�,)ree 4 tidy,state,and LP code)
206 E A, Ci- 1-rAzQLA, TN 47c.Gb
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
•
Address of authorized person (number and street,dry,state,and ZIP code)