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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou Year
, � FOR DEDUCTION FROM ASSESSED VALUATION
• State fvrtn 03709 (R71 / 6-09) , �.,�_�}
•�' ,.,. d Prewibed 6y DeGanrtreM of Laal Govemment Flnanca �\�d � l�1 •� -z� -1)
�,p_Q� � �.O•r•�� � - � il Mark
INSTRUCTIONS: � •
� FormAe "� �
To be filed in person or by maii with the CountyAuditw or Counry Recolder o� the county whe the pioperty is focated. �
Fiiirg Dates: 1) Real Pmperty: Must fila dunng fhe yearlor which the deducGon is sought. ���
2� Mo6ile / Manu(ectured Homes nof essessed as Real Property Must file dunng the M1velve (72) months tt��ud"rtor
6efae March 31 0l each year the deduUion is sought ❑ � em�dw
GIBSO
See reverse side for additional inshuctions arid qual�cations.
AppGren a or b - see re��yq��� m�,a� rse side) n '
/) �/�� a� Cl/1/� l�u�r .�l � i/I ! A/
m
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It rume on rt,md is QMuent Nan that al applkant �dirata Eelmr.
Name of mortgagee a mntraU seAer
Address of rtnrtgagee or contract se�
Name of assignee w other mmet or h
Aatlress ot as4m�ee (rcm�ber ard sm
ootle)
aPp�ifant o+m prapnty in a�ry other I It yes. what wunryl
y in Intla�?
❑ Yes ❑ No
GJ/-�/� l�U/3e�T �4
����� �
a������3n
�
- oU . � _ o�/ o�i /� 3a
ss unpaid az of Mongage / Con�aG iMehtedness unpaid as d Is ihe appli�znt the sde
Oate ot appGcatim /J� legal w equitaHe rnmeR
9 �I3 �D.' ❑ Yes ❑ No
'r'"LL�I
��
' 3 -`d' d• � '�
Whal Taarg Districl?
2� ��^I� �/ 2�
h V
������
Is the property in Qu�tion: MnuaOy Ass¢sed
�i Real PmPertY ❑ �!^^�!aM�
Has �hs Oedutlbn Deen requesteE m PropenY
far curtent yeaR
❑ Yes ❑ No
�
Date (rtqnN. daY. Yxa�
r�
antl foregoing infortnalion is We and correct arW that the applinn[ is a resident of IfMiana antl
I contract buyer of the atoremenBOnea property on date applicatlon is filed.
(own/e(_s fiAreme3 � Date (rtn�W, daY• Yaa� �
iw T Q • V"
nt (num6erantl sbee ory, slafe, aM LPCatl�
C�0 5oli..� �.Ii.vniv
Address of auUmr'¢ed person (number arM sUee; (3ry, stata, antl LP code)
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