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•4.�nv STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
-.a t FOR DEDUCTION FROM ASSESSED VALUATION _
Ii: 7 State Form 43709(R11/0-09) GI BSON �n{yy/OQ)U 2015
Presaibed by Department of Loral Government Finance �•'"'��'' "`"'��
File Mark
INSTRUCTIONS:
To be filed in person or by mail. -w^
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. r S
Must be filed with the County Auditor or County Recorder of the county where the property is located C.• y -�;
on or before January 5 of the immediately succeeding calendar year. -ou der
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the AUG county where the property is located during the twelve(12)months before March 31 of each year the OU 1 7 2015
deduction is sought.
See reverse side for additional instructions and qualifications.
Apdiwn ( er or contract b eresnccdons on reverse rQ. !/71 .�� sow
enneih t ' peon. and -b p G/e coflar —
Ta�>i�9 DistriU ey number/legal description rcecan purpbe
yyl..,.'T7�^'_�Lf7 aZ(a -l'r- a9-o'ZCYI- Jr/7-102/ (-J�/l/ ui
Assessed lvalu• $(Kirreal as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the a scant the sole
March 1,when ear March 1,current year �• dat�yf d'5/pOon legal or equitable owner?
TJ_• T /,42:00, — ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
It name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name a rtgagee or con efler n .
rSf- l a-/i0n4/ &nk CC al_rml
Address of mortgagee or contract seller(num r and ys pet,city,state,and ZIP code)
0'2.0/ inni1/2 f. ( "arm/' _ 2. Co2Y-/
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 Taxing 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 County Date(month,day,year)
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 afor�m�eennti000nnn�ed property on date application is filed.
Si ature nets fug time/�//4ybei LD�te(month, ay.ye r)
� /d r f IX� ���
Full resent address of applicant(n m and street,city,state.and ZIP code)
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.city,state,and ZIP code)