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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun s' vear
_ ; FOR DEDUCTION FROM ASSESSED VALUATION
.. State Fwm 43709 (R71 / 6-09) .
�' Presaibed by Departmerit o1 Laml Govemmenc Finance
� e ark
MSTRUCT70NS: ���
Fortn Ned with:
To be filed in person w by mail with the CountyAuditor or Counry Remrder o/the counry where the property is located. ,�
FiNrg Dates: 1J Real Property: Must file during the year for which (he deduction is sought. q�d��
2) Mob�7e / Manu(actured Homes not assessed as Real Property: Must file dunng the hveNe (72) monfhs
before March 31 of each year the deducGon is sought. � econ'1u
ciBSO c Nr
See raverse siCe for additiona/ inshuctkms and qualrficatbns.
I Appfi�nt (owrer�oonhaC b�yer - gee msficbonsym re�.x�side)
Distrin I KCY VOerl�a�� "� g' I O„{ _ w�
��
zd rahc d real property as d Mo tqr age / Conbaa irdeMeEnPSS unpaitl as
1, arrn1Y �ear March 7. cy�n(yeer� _
m, what is his / hu r.raU share of intuest?
IfowneO
name m mmrE a dtiFerent IAan that ot app6rara, ot0itlte Delow.
Name of rtnrtgagce or mntrad se9er /� _
'310 •
�LY�iIJ
A�dress W mort9a9� w cantraU seAer (nuri6er ard st
Name M asignee m otMr owner m Imldu of martgape
AdNCSa of asagnee (numbri an0 stree4 my. s+ate
Does appGmnt wm propaly in any oNer
munry in Indiara?
❑ Yes ❑ Nc
DrLurrion approucd in pre amount of:
20 20
�y, sYdte.
Dra��•cr \'0...����.........
Card NO. .p... ��1���`�........
H � �...Jl..� . �
20 � 20 I 20
J
RemN
unpaiE as of Is ihe apptirant the sde
legal w equilade axneR
n Yes n No
sPOUSe.
IS tl1C D�PPnY ifT OUMCM: MM12MA46.t.E
I] Real Pfoperty ❑ NmuallyA55eS5ed
. Mohae Fiane (IC 61.
Has this detlur�m Eeen reVUesteE m P�Y
ta curtent year?
❑ Yes ❑ No
20 1 20
I/ We certrfy under Ne penalry ot perjury that the above arW toregoing infortnalion is true and cortect arM ihat Ne applicant is a resident of Indiana arW
v.mer / contract buyer of the aforementioned pmperty on date application is filed.
�naNre (owrnrs fiAi name) Date (nronfi, day, ysa�
r r� - - - a . C� c� _ .., ..
tity, slate, eM ZIP mde)
autt�o�aetl by dWy esecvteC Power of Anomey w by IC F7.1-12-0.7
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Date (moriM, daY.Yea�
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