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"'n 5TATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
_ + FOR DEDUCTION FROM ASSESSED VALUATION
� $tdte Fortn C3709 (R71 / 6-09)
,' � Presaibed Dy Department o1 Ln�al Govemment Fnance
�81i(J
INSTRUCTIONS: �
To be fiied in person w by mail wifh Ne CountyAuditw or Counry RernNer o/ the county whefe the property is located. ���2Q Q9
Filing Dates: 1 J Real PropeRy: Must file durirng the year (or which the deduction is sought � County Auditor
2) Mo6de / Manulactured Homes rrot assessed as Real Property Must file dunng the hvelve (72) months
befo�e March 31 ot each year the deduclion is srought. ❑� �Re�°bu
See reverse side for additional instmcfions and qualilrcafions. _ C/ V____
Ta�u istrict " Key r/ legal EeSCriDtion Remrtl numb� Page number
4itTr� _?o.o(o-�oo-oo, 838-��� aoa9 / /
Assessed rahm d rnal piopaty a d Abrtgage / ConbaG intle6tetln�s unpaid az W Mortgage I Con�acc indeMetlness unpaitl as d Is Ihe apd�t Ne sole
Ma�tli 1, anrnl Y� Maich 1, wrreirt Y� Eate of aPp�atim legal or eWitade ame/)
�� Q (� ❑ Yes ❑ No
I( no. whal ts his I her eraU share o( interes2? If owrred wiN sommrre otlrer ihan spouse. iMircate wah whom
tt name m n.mtl a Ailferent fhan Ihat ol aPP��t �dicate beb�.' Is Ihe property in Question: MnueM Assessetl
� ❑ Rea� amaenv ❑ ���a�N �
Name ot mortgagee or contraa
mon�ag� or mntrad se�er (nwMer and stree4 �y.
signea or other o�mer or halder at mortgage
A4tlress ol as4grree (numbar aM stree; cdy, shfe, erd LP cade)
Dces epplinN ovm propeny in any oNer
m,nty in ��aa`w?
❑ Yes
20 _
SignaMe W
amoum
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LP code)
COUNTYAG
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20 _ � � 20 _ � 20 _ � 20
Couny
20
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I/ We certify er Ne penalry f perjury that Ihe above and foregoing infortnaGOn is We and carett arW ihat Ne applipnt is a resident of Indiana aM
own �/ mn buyer of ihe fi2mentioned property on date application is 51ed.
� v(oMne/s/ ✓/ eN/ ^ Date (rtionlh. day, Yea�
( / in_ 'J/ n 9
^J
and ZIP catlaj
Power of Attomey w Oy IC G7.1-12-0.7
AdEress of authomed person (number amd sbeet, ciry, sfate,
Date (manN. daY Y��