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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
__ _ POR DEDUCTION FROM ASSESSED VALUATION
�• State Fwm C3709 (R71 / 609)
�' Preuribed Ey Department af tnd Govemrnent Firerce
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INSTRUCTIONS:
To 6e filed in rson or b mail with the Co�n Auditw or Coun Recorder o! the coun where the ro Farm med wim:
a� r �r n ry v a�m rs ��«a. JA 1�Z(�
Fi7ing Dates: 1) Real Pmperty: Musf (le dunrg the year /or which the deduction is sought. un Auditor
2) Mo6ile / Manulactured Homes not essessed as Real Property: Must file dunng the tweAre (12J months �
6efore Maich 31 o/each year the deduclion rs soughG C.'� County Recorder
See reverse side for additronal instnicUons and qua/ifications.
np�(owrierwcontraC6uyer-seeresuir�a�ns verseslde) TYAUDITOR
I rdNe oF real ptop¢rty a ot
anrnt yrar
316 �I15 / i12f BYLf2 S�IdlB O� VI(2fE5i�
Eesaj[y6n numEer Page rwmber /
��a -�oo-000. �S�-oo `�"o�o ys��
7e / Contraa indehtedness unpaid as of M�rigage / Cmtraa uWebteMess �mpadtl as d I5 the app�ant tlie sde
I, a�rteM year date of eppOmtion legal w epuitade oxnM
! 0 ❑ Yes ❑ No
rc ovmeE wiM someona oNer than spou.u, uMicate wBh wtnm
If naTe on recotd'a QRtM2nt tlun Uiat W app0pn4 "v�Eipte E¢bw.
Nartre of rtwrtgagee b
mortqagee «cmaaa
w otner ovmer or nower ot morigage
stafi. aM
PLdressota�r��mberaM � stete, �Z/PmCe)
I
Dces applimnt own propeily in any other If yes, �Mat m
��y��i�e�,aa n .,__ n .._
SignaMe
1/We
20
� � • . r a�i
ify undu the penalty of
mtract buyer of the afor
�
r
r t the above
ed property o
G
perty in Ouestion: ArvwaM AssesseE
Property ❑ ArntuallyAssessed
�='�-y �,�� �� -
,M,a,Ta�� �D/b �Sf3 s -
lo
20 � 20
�Date (moNh. tlaY. Y��
regoing infortnatlon is We end correcl and that Ne applicant is a resident of IMiana arW
appiication is filed.
Date (rtmM, day, yea�
��'=3<=Uc iso.s �'� /CiS�o; �/U S' �
Pelmn auUrorizeO by dWy esecuted Power of Atbmey or Ey IC 61.1-12-0.7
/ddre55 W autlror'ved person (number e� street �ry. state, and ZIP cade) .
Date (manth. tlaY. Yae�