Mortgage_Tooley^� STATEMENT OF MORTGAGE OR CONTRACT INDEB
_. � FOR DEDUCTION FROM ASSESSED VALUAT� �
� State Fam 43709 (R71 / 6-09)
�' ,,,, � a�esoibea M oepartment ar l.oca� c»vemment Firance
�VSTRUCTIONS:
To be filed in person w by mail with Ihe CounryAuditor or County Recolder o/ the wun�
Filirg Dates: i) Real Pmperry: Must file during the year for whicb fhe deduction is sought.
2) Mo6de / Manufactured Homes rat assessed as Real Property Must fi�wd
6efora March 37 of each year fhe deduction is soughf.
See reverse side additional jnsVUClions and quali�cations.
qppEant (mriar buyer - see restrictions on reverse siie) .
7' Ke rwmber / I al tl
TEDNESS Coun Tovmship Year
$--/ � File Mark
C"F' Y"f �''+ Farm t�ed wkh:
f p rs located. ���,,,JJJ
� County Auditor
�i Ne (12) rtanths Cpunry Recorder
�
anrg i Y e9 D
_al- � - o0.3sca
A.sessed vWue af rnaI WoP�Y as AbrtOaAe / Contraa' ted�ress unPaid as Mortgage / Contrarf intle
�11a�ch 7, arrrnt year Mart3i i, artent yeer date of appGCation
If m. what is tus / hu eratl share ot inferesf? If ovrtred wiM someo�re other Man
If rartie m recortl is Eilfelenl than Nat Ot dppLtant'oMita[e Celo�r.
Name o( mortgagee a mntrar� seller �/`� .
Address of mortgagre w contrad se�er (num6er and street ', state, artl LP cada) . /�_
Name o( assignee or ahel vnner or hdder M mongage � �
AACress of assigriee (numberaM sbee4 �Y. �fe. and ZIP code) 1\
� o ��•'' �
ooes ap�i�ru w�„ aoperty � a�y weer u; 1 �.
munryinlMia(u? `C� l �
❑ ves ❑ No �Y3�
amoumat CaC�` IlN-•�—
`�.. [/\� 1lY
t� �.l
I2d�l � 20 _
U
I�aWre of �Y di
I/ We certly under fhe penalty f perjury
owner I contract buyer of the aforemenlic
tlent adAress d applirant (nu,/mber
7t��� L Gr0
authwaed Ey EWy executed Powe�
numDer
���d�� �����„��
le�l d eQURade aw�reR
❑ Yes ❑ No
spouse. uMkate wiN whom
Is tM prope`ty in QueSUOn: Mnua�y Assessed
❑ Rea� Provenv Q !�!?n!aM Psse� . . .
�uaim Eeen re9uestea m propGly
� n Yes ❑ No
2q_ _I- _ 20_ 20_ 20_
above and fo
�erty on date
dty, sfate, aM
: o( authomed persrn (number arM 5Lee4 city. sbfe, and ZIP cotle)
�
Counry Datc (monM. daY. l'ea�1
irtnaGOn is We and cortect and Ihat Ne applicani is a resident of IMiana aM
is filed.
/a7 /,
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