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STATEMENT OF MORTGAGE OR CONTRACT INDINt un Township Year
i�o._ 1y P
vile FOR DEDUCTION FROM ASSESSED VALUA
:.'=a„ State Fonn 43709(R11/6-09)
Prescribed by Department of Loral Government Finance
2�\5 F
INSTRUCTIONS: OR 2 o File Mark
Farm tiled with:
To be filed in person or by mad with the County Auditor or County Recorder of the county where the p 'pe �I'' -ted.
Filing Dates: 1) Real Property Must file during the year for which the deduction is sough �, . NM 12 County Auditor
2) Mobile/Manufactured Homes not amassed as Real Property Must Re. -�� {` F cf '¢
before March 31 of each year the deduction is sought . t4 GOUN1 County Recorder
See reverse side for additional instructions and qualifications. G)gS
App (owner or oars buyer-see restrirbww re`vevveersesltie) f
T D ' j al description`u) Record Page number
aV A-10 4'41 Leo-o5-- 57- 110 030 7F6 0/7 ( IOr3 �
Assessed value of realty as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
March Latent year March 1,current year date of appca6on legal or equitable owner?
/5O e t93. ❑ Yes ❑ No
If no,what Is his/her exact share of interest? If owned with someone other than cp..rte,indicate with whom
If name on record's different than that of apprcan;indicate below Is the property in question:Annually Assessed
❑Real Property ❑AnnuallyAssessed
Mobile Home QC 6-1.1-7)
• •of mortgagee or contact seller 4 -
.Oi •it" ,I. I/ 4_._ ' J . - 1J. -
Address of mortgagee/ con,. -1 er(number and street,city,state,I ZIP code) �
Name d assignee or other owner or holder of mortgage � .._Q,0 f 1vv.h .
k.
/'/` ,Q
Address of assignee(number and stree;city,slate,and ZIP code) �/-��-(��Ip�)� � l
Does applicant own property in any other If yes,what county? • What Taring D' ��
county in Indiana?
El yes ❑ No D85 _
COUNTY AUDITOR
—
Deduction approved in the amount of -
20 20 20 20 20_ 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 I contract buyer of the aforementioned property on date application is filed.
Date(month,day,year)
/
`/ 3/20(20,
Full•so t• ^of ppacant( •-r and street a1y,state,and ZIP code)
/
• 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 city.state,end ZIP code) .
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