Mortgage_Smith :a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS - County Township Year
tilFOR DEDUCTION FROM ASSESSED VALUATION
State Form 93709(R11/e-Prescribed d
Prescribed by Department of Lo Government Finance FILE
He Mark
INSTRUCTIONS:
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To be filed in person or by mail with the CountyAuditor 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 ❑ Cou 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 .,• �llintril;ty Recorder
See reve side for additional instructions and qualifications. G I B SO N - 7. • - . D a =
vmer or contra:buyer-see restrictions on reverse side)
T t „V/- y d ' Record niter Page number
�� acre - Zo-o5 - yo1_ooa. Yn-poi I -1 ;877
Assessed value of real property as of Mortgage/Contract Indebtedness unpaid as of Mortgage/Contact indebtedness paid as of Is the applicant the sole
March 1,parent year March 1,current year date of appb a)tion legal or equitable owner?
y0 as El Yes 0 N
If no,what Is his/her exact share of interest? If awned with someone other fhan spouse,Indicate with whom
If name on record is different than that of applicant imitate below: Is perty in question:Annually Assessed
eal Property ❑Annually Assessed
- � Motile Home(IC f-1.1-7)
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Name of mortgagee or contract seller Y ` M
Address of mortgagee or contract seller(number andd street,abc state,and ZIP code) r`Cl
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any other If yes,what county? • What Tmdrg Distriri?_ --
_ -—
county in Indiana?
❑ Yes ❑ No
COUNTY AUDITOR nC COMIC
r
Deduction approved m the amount of: ynryss���l,_(f tM-11
20 20 20 20 20_ l L al Vl q
Signature of County Auditor , ` County '
/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 contact buyer of the aforementioned property on date application is filed. .
X Stature(ovmert tun name) N. i Date(nwdh,day,year)
•
Full resident address of a Zst(number and sheet,aby,state,and ZIP code)
91/ 7/ 2! . oD S FRA-1jct sco LN ci7� g /
Person authored by duty executed Power of grey or by IC 6-1.1-12-0.7 / Date(month,day,year)
Address of authorized person (number and (street city.state,and ZIP code) .