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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ 4 FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R71 / 6-09)
� ! Presai6ed by Departmenl of Lacal Govemment Firanca
ie
wsrRUCnoNS: t�
To 6e (led in person w by mail with [he CounryAuditor or Counly Recorder of the counry where Ihe property is located. M U�� �
Fifing Dates: 1) Real Pmperty: Must Ide during the yrear for which fhe tleduction is soughL County Audilnr
2) Mo6de /Manufaduied Homes rrot assessed as Real Property: Must file dunng the fweNe (12J monfhs C�J.
before March 37 of each year the deduction is sovght. ty Recorder
See reverse side for addiGonal instnaGons and qual�cafions. G
Appfranf (owneS a�+��� buyer - see m_V�'rdory on reverse sde)
�`Jc��ox� .Z -ao,��-�ov-000.3�3-00 0/ s�.o
Psseasd vah�e of mdl qopeM1y as of �.A��(qyg e/ Contract iMebteEness unpaiC az U Mortgage / Canvact irWebiedriess unpaid as d Is Ne app�rcant the sole
Mard� 1. anvrt ym Marrh 1. artent yrar Cate of apptication legal a equitade owne(1
` �j Q Q O ❑ Yes ❑ No
If no, wha� fs �'s I tcer evact share of interest? It ovmed wiN wmeo� dher than spouse. indrcate with whom
If name m �ewd a dMerent tlan ihat ol aPP�^t v�dirate Celovr. I5 Me D�PPrtY in Ouestion: MrwaQy Assessed
❑ Rea� Ropeiry ❑ nrmua�yAsse�
GT••'l�r I
assignea w oNer owner or holder of morigage
rdy,114te. eM LP aode)
AOC2ss ot assignce (num6er a� shee4 my. slate, z+M ZIP tode)
/�r N w nl� a�-
Ooes applimnl ovm pmperty in any oNer I( yes. xhat count�?
munlv in Indvria? � � .�
20 � 20
,q 1.78 Ac -
What Taring DavkY1 Has Nit � Eeen repursted m P�Y
for amsv yraR ❑ Yes ❑ No
COUNTYAUOROR
\ �1� 20
Counry
I I We cert'rfy uMer the penalry of pe�ry Nat the abov tl foregoing informaUon is We anc
owner I contracY buyer of the afaementioned pmperty date application is filed.
Si9fa (o +ieme)
FWI resident o ap�nt mDer an� sLee4 �4'�.,�te, antl LP mtle)
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Person autM�¢etl tlNy e<ecvted Power of Attorriey or Cy IC 67.1-t2-0.7
Pddress of aulhatred person (numberaritl sbee; dty, sfate, antl LPcade) .
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