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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__, s FOR DEDUCTION FROM ASSESSED VALUATION
• State Fwm 43709 (Rt t/ 6-09)
�' 1 Preuribed by DepartmeM of Loml GovemmeN Finance �
�«.
INSTRUCTIONS:
To be filed in rson or b mail wifA the Coun Auditor or Caun Recorder ol the coun whe2 the � 1
a� r ty ry ty a�a�m � ��r�. S E°i
Filirg Dates: 7) Real Pmperty: Must file during the yea� /or which the deduction is sought. County Auditor
2) Mo6ile / ManWactured Homes not assessed as Real Property: Must file dunng the fwelve (72) monMs C
befo2 March 37 0/ eacA year Ne deduction is so�ght. unry Recorder
See 2verse side for additionaf inst/ucfiWns and qualficatbns.
Aoo&'ant (owner accontraa bw�e� - see r9stu'��brss m rererse sidel .
� tr'xY Key rwmber / legal desaiption '
n+m1a Yem ��Y �� �1 Qart�em9 y er�btedness unpaid as of date
� V �"�'� .
�
If name on
Name of mortgagee p mnbaU seAer
Afldress d rtartgagee w contrad se0er (nuMer ard sboe4 �l: slafe. aM
mwtgaga
nea�ess
Dces appli�anl ovm property in any aNn
counry in IrMa`u?
i. ❑ Yes ❑ No
20
I I We
It yes. what munty.+
COU
20 I 20
number
7/O
as of Is Ihe a
lega� a
If axned wiN someorre other than spouse, md�te with whom
Y� u No
Is ihe property in question: Mnua�y Pssesse0
�Real Property ❑ Mnualyl�ssessed
M1WVIe Fbme (IC 6
DT�\YCT N�•'�/��1,`,!.......
✓„�T1 � l�� � • . .
v •••
CaTd ��' ' � t�
y�+ �\.,�,�y��/ � ' __.. � Wu�teE m property
R \ _ _ � .... �eaR � ves ❑ No
���
Date (rtronth. daY l��
20
under Ne penalry of perjury Mat the above and foregoing infomialion is W e and cortect arid that the applinn[ is a resident of India� arM
act buyer of Ne aforementiwied property on date application is fiied.
s(Wf rame) n t Date (rt�onfh, daY. yea�
stare,
Pers.on autMi@eO Dy Otdy executetl Power of Attorney or by IC G7.1-12-0.� o I Date (monM, tlay,
P4dress of auUia'ved person (numOer a� sneef, tlry, sbte, an0 LP mde) .
y