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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTED �SS I ship vear
� FOR DEDUCTION FROM ASSESSED VALUATION
• State Form 43709 (R71 / 609) r_ f q S�O (�
i I Preuribed M DeparN�eN of Loral Gmiemrtrent Frence G 1. D
� File Mark
INSTRUCTIONS: �
Tobefiledin . �m���
person or by mail wiN the CountyAud'Rw or Counry Rern�der of Ne county where tAe prope�s
Filirg Dates: i) Real Property: Must file during Ihe year tor which the deduction is soughG nN rr((11 TY A DI� Counry Auditor
2) Mobde / Manufactured Homes rwt assessed as Real Ploperty Must Sle during the hi�$ r�eJ mp� � ���, Reco�du
6efae Maich 37 0l each year the deduction is soug�t �
See reverse side fa additional insVUCtions and qualifications. ��m h-� ��
Apdirani(ownerwconvay(6�ryer-seerashictlmsoprav^erseside) .
ia�-av-0a-aoa-cb�
W Mor�qage / Contran inde6tedn¢s unpaid as of
�i :'I
what ¢ his I her e�ct share of interest?
If name on remN's Q�Rerent than Nat ot apP�^L �irate Eeb�r.
r�ame m �,oneav�
�i �
end svrec �: s��, aro
w other owner or hdder ot rtvtga5e
AEd2ss o/ assignce (number and slree4 �: �e, and Z/P code)
eppli�nt axn yoperty in any oNer
y In IMiana?
❑ Yes
cCOn approved in tice amount of:
20 20
RecaN numbv Page number
/ -CY� �009 �os
Morigage / ContraY mEehteEness unpaid as d Is Ne eppfrcant Ne sole
Cate of appOption legal a epuiiahle wmeP
�/i Yes ❑ No
If owrred with someorre other than
s ihe Property in O�a�: �nually Pssccud
�fieal Property ❑ Mnualy0.ssessed
hbbile Flwne pC Frt.
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VJhat Taa�ry - � �\ Q)
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Dl ���'Cl 1�� •..........
COUNTY Al1DROR
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20 � 20 _
inature W CamtY AuEimr „I I^ I Counry I Date (rtnn7n. OaY. Yeen
�!/ 1 0{
I/ We certfy urder the penal of perjury Nat the above and toregoing infwmalion is We and cortect and that Me applicant is a resident of Indiana arW
owner I mntract buyer of the aforementioned property on date application is filed.
��aw (oxner's hArame) Data (nWh. daY Yaa�)
�", /%�� .«� iz -.2 fs- 09
tl�ent eEtlress of appGrant (number ertl stieeS �l; s+a!e antl 2lPpode� --� � n
author¢ed Ey Mdy e<ecuted Pbwer otAnwney or by
P4dress ot auNrnved person (number a�M sLee; ciry, state, an0 ZIP code)
�ace Grcvu4 Ea1: �ead
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