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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
_, FOR DEDUCTION FROM ASSESSED VALUATION
� $tate Fortn C3709 (R17 / 609)
�' Fresaieea M�rn m Local Govemme�a Ftr�arke
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INSTRUCT70NS: F� ��
b be ked in person w 6Y �il witlr Ihe CountyAudifw or Counry Recorder o� fhe Wunty where (he property is bcated. S[ p �4 Z Q � Q
Fi/ing Dates: 7) Real PropeRy: Must file dunrg fAe year tor which Ne deduclion is wught `"�� Counry Audimr
2) Mobile / Manulactu2d Homes iwt assessed as Real Property Must h7e dunng the twelve (72) rtwnths
6etwe MarCh 37 0/ each year the deduction is soughG Cou Recordes
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See revarse side 7or additbnal inshuctions arW qualficaGOns. �
�Y
A�sed �rahm d mal p�opc;y as d
A1a�U 1. arta�t Yw
If ro. what fs tus I lm era(x share Of interest7
If fwne m rtmd s QAterent than ihai
—r vv � v
Abrtpage l Contraa 4debtetlnm unpaid
Ma�d� 7, arrem y�ar
Nartre of rtnrtga9e8 or mnVarl seBer /�
!i�
Add�ess of rtnrtgagce or contrad se�er (manba� and sveeL d�Y. 5ste. a
Name W avsgnee or ather ownn rn hdder M rtprtgage
AdCress at as�ee (numbar eM saee4 �l: slate.
Does eppliont own property in eny oNer
mun[y in Indana? �
❑ Yes
Deduman appoveE in the amount oE
20 _ 20 _
�O ' OGCA V D U �
Igaga I Conttau "v�Ceb[etlness unpaiC as d �s Me appGrant the sde
°`a°�'3o,�c,v ����
❑ Yes ❑ No
sameo� oNar than sPa+�� ind'uate Wth whom
p properry in OueSim: Mmia➢Y Assessetl
rxe� aoaenv ❑ rvmuaq' a�ss�
Mod7e Harie (IC 61.
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I ir �. �� �nm I wi,� r��y oso-�n I ro a;��n � o�
No
GOUNTYAUDROR
I 20 I�-11'�Jy� I' t ' • _
i i r� ��
��tu�e d Camb Ntlitor �v
I I We certNy under Ne penalty of perjury that the ahove and twe; �/ � ���( (� /
owner I mntract buyer of the aforementioned property on date aP � q/� _
��anue (ownars 7u0 ry?me) �
9a:e,
Ve�^ (num6eraritl sbeet dN stale, and LP mde)
reQUrsted m p�aperty
❑ Ye5 ❑ I
I 2(1
wnG7. tlaY• )T.e�
is a resident of Indiana aM
Date (monfi. EaY• YgeA
Date (manN. EaY. lse�)
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