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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
__ ; FOR DEDUCTION FROM ASSESSED VALUATION
Slate Fwm 43709 (R11 / 609)
� Presm�e0 M DeC�N of Local Gmemmerrt Flrerce
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INSTRUCTIONS: �m�v�t
To be ned in person or Dy mail with fhe CounryAurlitor or Counry Recorder o/ the co�nry whele the pioperty is IocatedQ U � `i L � i �
Filing Dates: i) Real Pmperty: Must fik dunrg Me year /of which Na deduclion is sought � Counry Audimr
2) Mo6de /ManulaUu2d Nanes rat assessed as Real Properly Must Ae dur"urg the fwelve (72) rtanths r-i �� R��
6efore March 37 oleach year the deduction is sayht `Yri bJ�/
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See reverse side for additional insLUCtions aM qualificatbns. _, ____._ V __ . V___
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Me�d� 1, am�n y�r Mard� 1, a�� ]�nn n i II 3 O C� tlate of aGP���
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rc ro, what is his / trer exaa shara ot interest?
It name an RCON e QiRemn[ Nan Nat ot app�Cdn4
Name ot mortBeBee m m�tract
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w other awner w hoNer d mortgage
PAtlress W asignee (number en0 rneeL mY: �. antl
Ooea aQptirent own C�Dcb in ai7' oNer
munrymlydiana? I—I ..__
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2q � 20
1/ We certfy urWer�e penatty.M perjury
owner / wntraa D r of Ne afaementic
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❑ Yes ❑ No
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h tlie ptoperty in Ouestion: MnueOy Aaessed
� Real P�npeKY ❑ Armual�YAs�.sed
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above and (aegoing intortnation is true and corteG and that Ne appGrant is a residerrt of Indiana aM
�erty on date aPP���n is fiied.
Data G�• �Y. Y��
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