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^�� STATEMENT OF MORTGAGE OR CONTRACT INDE
__ .• FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R11 / 6-09)
�' ,,,, f Presaibed by Departmerrt orLCW Govammarrt Friance
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INSTRUCTIONS:
To be lled in rson w b mail with the Coun Auditor w Coun Recorder of fhe coun where the F� �� �� ��
Pe Y �Y b b P�PertY is located.
Fi%mg Dates: 7) Real Pmperty. Must file durr�g the yrear /o` which the deductlon is sought. i��
2) Mo6de /Manufedured Homes not essessed as Real Property Mus! rile dunng the twefve (12J monNs �
betore March 31 0! each ysar the deduclion is soight.
GI N OUNTIry �R
See reverse side (or additionef inshuctions arM quelificafions.
t(ownerm buYer' 2s4ifDUns rewrse ' e)
Ta�d Distriu • Key n�mber / legal tlesaiption Reco�d rwmber Page numhPi
a-iy- l S- 303-00/. aa. -o0 7 oo'S 8��
A�sed rahc d mal of A�Wt}p�ge / Contrau Webtedneu un0� az N Morigage I Contrarl uWebtedness unP� as of Ls the eOP�� Iha sde
Marfh 7. al�e�# `pr Mam}i 1, airtent yw data ot aPP�� IaJa� or eWltdble owne(1
D OO O ❑ Yes ❑ No
tt ro, what fs h'a / Irer eno shafa of interest? It owned wiM sameorre othar Ihan spouse.'udirate WM Mmm
re(ne m �em�d
ar contrad sv�er (nvn6er end shaeL uN. sbfe. erd LP code)
Name ot assgnee w othel ovmer or hdder af rtqrtgaga
ACC�ass ot assignee (numberard saeeC �l: smte. and LP cade)
Does ePyitant ovm property in eny aNer If yes. whal �
munryinlna'vna7 � Yes ❑ No
Orauclion app'rnad in tlre amount of:
zo � �_
Is Ihe W�Y in Ouestiw�: Mm�aM Assesse0
�Fteal Property ❑ Minually Asse55ed
awaie r� nc s
� Drawer NO..��?.'..�. :... . �
[a•m.�i�_nmi
20_
Caunry
Card NO. .. �..� �:�.......
��� ���
Date (rtar�. tlaY
No
I/ We cerOfy uMer Ne penalty oi perjury that the above and foregoing infortnalion is We and cortect and �hat the applirant is a resident o( IMiana aM
rnmer I mntrac2 buyer of the afwementioned property on date apP��� �s filed.
�� (ownen M1A�ne) � Date (rrwWi, daY. Y��
dWY exewtetl Power
Pddress of aWia"vse xrson
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a Dy
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