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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
__.,_ - FOR DEDUCTION FROM ASSESSED VALUATION
• State Fortn 43709 (R71 ! 6-09)
�' ,,,, � Presaibea q �epartment of Loca� Govemment Franca
�
INSTRUCTfONS: F�r�
To be filed in person or by mail with fhe CountyAuditor or County Recorder of the county where fhe property is located. �U L����
Fil'mg Dates: 1) Real PropeRy: Must file dunng the yearlor which the deduc[ion is sought. � J_ Counry Auditor
2) Mo6Be / Manufactured Homes rrot assessed as Real Properfy.� Must file dunng the tweNe (72) monfhs C r�
6efore March 37 0! each year the deduction rs sought. unry Remrder
See reverse side (oradditional insfructions and qualificafions. ITOR
MMJ�a�umerorwntraUbvyxr-see2sMUiurSpnreversesytl€f� � ,
Yi" � - - /'f o,3 - �O. 3 ��o � �l�/od r"1 Y
vWUe d real of Mor(qage / Contraa "udeCteEness unp3iE az of Mortgaqe I Contraft uMebtedne55 unPaid as o( Is Ne eCP��i Ne 5oie
Mart1i 1, ar2nt year Mard� 1, artent yeer date o( appGcation�{�� legal w equitaNe a�+�e(�
pJ CP ❑ Yes ❑ No
H ro. what's his I her e�mU share of interest? If avrtred wiN someone othu Cun spouse. iMirate wiTh whom
If name on recad is dMerent Ihan fha� of aPP���• uMUa� Gebvr Is WoVertY in QueSDm: Mm�aAy Assessed
, Rea� Rovenv ❑ %vuiva�N Assesed .
or tMtrari seller
e or contraci seAer (n and yE
l.
� o�er owner or holder ot morcgage
ciry, state. aM Z!P co0e)
(numDer aM sheet �: �e, and LP code)
Ooes appli�ant o+m property in any oNer
couky in Ind'ana? ❑ Yes
Deduc6on appmved "c� tlre amoum
� �.
sigrewre W CwmH nwilor
= � — `7' o % AG'
If yes. what munp? I Nrtat Ta�tlng Oistntl7
GOUNTYAUDROR
20 � 20 _
Counry
>ted an property
Yes ❑ No
� Drarucr \'0..��I a —
I/ We cerofy under Ne penalry of perjury that the a6ove arW foregoing infortnation is W e ai
...:'`.....
owner I contracl buyer of Ne aFOrementioned property on date applicatlon is filed.
�" ��n�," i Card i1'O. .. �9�' '` —
;, .,f,, , _, •,..
� Fu� re�ident address of app6cant (num6erand streeG dry, stata. aiM ZlPCade) ' � • • • • •�• •• Q�; • • -
� 9z ' s� o�.w � r,� � S�,000. i.
Pelsan authotaetl Gy dWy esecutetl Power of AilaneY ��' IC 67.7-12-0.7 � Oate �niu.�.... --.. ,. .
��s of author'aeA person (number aM strect tlry, stafe, an0 zIP oode) .
�1 � _ _ _
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