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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
�„: FOR DEDUCTION FROM ASSESSED VALUATION_� j5
- State Form 43709(R1116-09) F File Mark
Prescribed by Department of Local Government Finance
•S7RUCTIONS:
n r pg 'n. Form filed with:
ro be tiled in person or by mail gp
with the County or County Recorder of the county where the rtp
FiTrng Dates: 1) Real Property Must file during the year for which the deduction is sought 1 County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)month
before March 31 of each year the deduction is sought - County Recorder
See reverse side for additional instructions and qualifications. C I DSON COUNTY AUDITOR
Apprint(owner or contract buyer-see me7 re rse side
0 C e nd } / C'-e I e.V
Taring D l Keyes umber/legal description / Record number Page number
z,41e I��--/a-ll9 /Dv'-0 0.3. 7. 0? -4012 200 L5793
Assessed sabre rf real property as of Mortgage/Contract Indebtedness unpaid as of Mortgage!Con act indebtedness unpaid as of the app5ranl the sole
March 1:parent year Meech 1,.q�rtgnt}germs date of aPPr�tion legal a equitable ovmerl
UXo�J(J ❑ Yes 0 No
-
It rio,what is his/her end share of interest? If owned with someone other than^pine,indicate with whom
If name on retard S different than that of appficant,Indicate belovc Is the property in question:Annually Assessed
,a2eal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller �
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,city,state,and ZIP code)
•
Does applicant own property in any other If yes,what county? • What Taring District? Has this deduction been requested on property
county in Indiana? for current year?
❑ Yes ❑ No ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of: •
20 20 20 20 20 20 20
Signature of County Auditor
a 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 afore r entioned•roperty on date application is filed. .
Signs. ;3,'.�+�% / ��� Date(month,day,
Full _'..4 address of applican umber and sheet,a , /�. ..LP e
�9 w � mow.
4 -
Person authorized by duty 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,and ZIP code)
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