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"'* STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
__ : FOR DEDUCTION FROM ASSESSED VALUATION
• State Form 437W (R71 / 6-09)
,' ,«. � P2svi6eC by �epartmeM o( Lncal C»vemmeN Finance
lNSTRUCTIONS:
To be filed in person of by mail with the CounryAUditor or Counry Recorder o7 the county where the pioperty is locat
Fifrrg Dates: 7J Real Property: Must fde during the yrear Por which the deduction is sought.
2) Mo6de / Manufactured Homes rat assessed as Real PropeRy Musf file dunrg the fwefve (12) months
6efore March 37 0/ each year Ne deduclion is saght.
See reverse sMe for additiona/ insfrucfions arrd qual�cations.
AppSCant(ownerarcontray�Wqg�-see/eshicpw�smrei,xrsevde) _ ,
�����
Y�
ttnameon
Name of rtnrtgagee «mntract se0er
n fq�tyAuditor
�LN C�aUtity Recorder
-' � - - a01- 00� .a 3Q - p _._.
ge / Conbaa irdehtednrss unpaitl as ot MMgage I Cantrafl iMe6tetlr�s imGaitl as of Is ihe eGP�t Ne sde�!
1. Cate of appfKation legal u dryritatle owne(!
�� ❑ Yes ❑ No .
If owned wiN someorre other than spouse, iMxate wuh wlwm �
Delo�r
naarea or nar4ia9� or ca,o-aa senu (wmoe. erd street �r.
o( assignea w oMr1 owner w halder of mortga9e
��D, cur��P��
���,� �
InOiana?
� O t t V� O` 11OROR
DeducGOn aPWrn'ed'o� tlre :
Is Cre property in qurstirn: MnuaOyAssessetl
❑ Real Pioperty ❑ MnuallyAsessed
Has Nis Uedudpn �een reQUrsteO m pmprriy
ror wrrem yea/?
❑ Yes ❑ No
20 _ _ 20 20 _ 20 20 _
Sigr�anue M Camry awilor \ `f� Counry Date (rtqnrh. daY. Y�+)
e�
I I We certi undef ihe nal of �
fy pe ry perjury that the above and foregoing infortnalion is true and cortect arW that the applicant is a resideni of IrWiana arM
owner I contract buyer of the a(o2mentioned pmperty on date appliration is filed.
SignaWre (ox7mfsL4name) n . � Date (monfh. daY.Y��)
tiry, slate. arM ZIP ootle)
Pelson au0ofm.d Ey duly ezecuted PwM o(Aftomey w Cy IC
and LP oode)