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"�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship Year
FOR DEDUCTION FROM ASSESSED VALUATION
• State Fwm 43709 (R71 / 609)
� Presai0ed �y Departmerd of Lod GovemmeM Fuarce
INSTRUCTIONS:
To 6e (ied in person o� by mail wifh the CountyAuditw or Counry Reco�der o/ Ne counry where the property is iocated. F �
Fdhg Dates: 1) Real Property: Must fi7e during the year (or which fhe deductiar is sought. unry Aud'rtnr
2) Mo6de / Manufactured Hwnes not assessed as Real P/opeRy: Musf fi!e dunrg Me hvelve (12J months ,�1'p 4�u,.,
betore March 37 of each year the deduction is soughf. R�y�plY�g� yef
See reverse side fo �.?�inshuctions and qualifications. �, ^��,_
AppfxaM (owrer toritraG bN'Er- resnic8+� on ieva+se side) . �% . � n ��
Ta�drgDi - Keynum0er/legaltlesaiption
C' a�-� �-,� -� 6 a
Assesse0 vah�e d mal pfapaty aa N Mortpage / Contracl iMWtetlness unVaitl as ot
AfmCh 1. finW ym March 7. tLrtenf yeer
J ro. what fs his / her e�p shara ot intrmt? tt wme�
Ii narne m remrtl's QiR�t Nan ttNt W appBCaN, c�Aifate DeIaK.
Name ot mort4a9 mntract se0er
Address of mortgagee w mntrad seAer (n erM - . —� --�
Name of assignee a dha owner or halder ot mortgage
ALEress W assignee (number aM snee; tlly. slafe. aM ZIP a
Dors applimnl own properiy in arry oNa If yes.
counry m InOana?
❑ Yes ❑ NO
Detltxtion approved 4i tl�e amaunt af.
20 _ 20 � 20 _
I
sgnawre m Camd nuanor
I/ We certify urder the penalry of perjury that the ab
owner I contract buyer ot the aforemefrtioned proper
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F appGrant (num6eranE sbee4 state, and Zl )
���i� � r�1a�n �, (�r� 1��. Cc�-4e.�
Per„on au�ezecutetl Power af Attorney or by IC 1.1-12�.7 `�
Mdress of aWiarrsed person (number aM stree; dry, stafe. an0 LP arh) .
tgA]e I GOn78U Cf4e0fCM¢53 �mp3M M Of IS M¢ BppOCdrtt the sde
' o( aGP�tbl IC�dI Of eONI2bIC OmMR
❑ Yes ❑ No
someone dher Uw� spouse. md'rcate with whom
Is the VoGP+�Y in Question: MnueAy AssesuW
I Property ❑ Annually FlS5e55ed
blobBe Fbme QC Cr1.1=�
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