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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS un o ip
:.--- �
FOR DEDUCTION FROM ASSESSED VALUATION •
Stale frortn 43709 (R71 /6-09)
`' yw d PleufibeE by Departmenl af Ld�l GwemmeM Frence
F���a�i s 2o�z
�TRUCT70NS: F� �� �:
7o be �fed in person w by mail with the CountyAuditor orCounry Reco/der o/ fhe county where [he property is located. C. J. �y
Fifing Dates: i) Real Pmperty: Must file durim� the year Por which Na deduclion is sought. � Coun d"
2) Mo6Be / Manufactured Homes rat assessed as Real Pruperty Must file during the nvelve (72) months n �R
before March 31 o/each yearthe deduction is sayht BS6N CI�l�Y OR
_ See reverse side for additional instructlons aryd qualifications.
1
AsxessW reWe d mal P�P�`/ ��
Mardt 1.0.vmrt YP2�
If ro, what ¢ ha l lcer esaa share of interrst?
If name m mmN s EitFerent Nan that ol appl
Name of mort9a9ea or Wntract 5ellet �
�ldress of mmtgagce w mntraU seller (num
�
Name of assignee or otfm! awner or hdCer of
AtlCress ol a5svgnee (number end street �1:
Oces appli(ant o.m prope�ty in any ot�er
munry in IMana?
❑ Y¢5 [
1
I
Dedurdon approved 4� ihe amount of:
20 _y .� _ 20 _
f //� /. vU
'IMngape / Contract "vitl�ted�s unpaid az N Ma
Martli 1, artent year daL
If owneC xT�
nt uWipte Cebw
martgage
state, and LP cotle)
If yes. what wumyl
No
I/ We certify under the penalry oi perjury tl
owner I conVacl buVer ot the aforemention
(num6erandstre
Is U�e apP�t the sale
legal or equipWe ownel.+
❑ Yes ❑ No
spoum. iMinre wiih wham
�e proPertY in purstion: MmiaM Assessed
Real Property Q Armually Pssessed
Moale Home (IC 6
��, e2—/ O /.�5�
Nrtal Ta�g Da1�iU7 Has N's deduGia� Eeen reQUesteE m propelty
for tutrent yeah ❑ Yes ❑ ��
COUNTYAUOROR
RL-L b�f�' ApAm �
ia -�i9�
Pasan auUror¢etl Ey EWy exewced Po�er of A�tOmey or by IC 61.7-72-0.7
�Idress ot auU�or"¢ed perewi (numberaM sbeeL cify, sfafe, antl ZIP mtle)
20_ 20_
Date (monfh, daY. Y��
uW that the applirant is a resident o( Indiana antl
Date (monfi, dsY. Yma�)
Date (monN. tlaY• Y'��