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,. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Townshi vear
_ FOR DEDUCTION FROM ASSESSED VALUATION �
$tata Form 43709 (R70 /11-08)
� y,. � Presaibed 6y DePaNren� d Loral GwemmeM Finante
�NSrnucnoNS: MAY 2�i�n�9
To be filed in person a 6y mad wifh the CountyAWitor o/ fhe county where fhe property is located.
Fdirg Dates: 1J Real Property: Must file dunrrg the yeer /or which fhe deducGon is soughf.
2) MobNe / Manulactured Homes not assessed es Reel Property: Must file dunrg G�e hveNe (12) months be(ore March 3,1 each year
the deduction is sayht. �a �GS
SeereversesidefmaddkionafiruLVCtionsanOqualifm,ations. �N{V A_d1'(�R
/�oofxant (ownarr mMraci buvsr see resbirlians m roverse side) n1A'UII� ''_
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B ro. what is ho / hm e�atl share
C rmrtre on recard'a QRfereM �han Ihat a( a�n�. indimte 6abw:
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v mriUad se0er
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Doas aPq'ican� wm popeAy in vry dher
cwmr m h,cra�a7 p res
20 l/ 7 I 20
year
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I/ We certify untler the penalry of perjury U�at Me above and foregoing c�tortnation is true arW correct and that the apqiwnt is a residenl of Intliana aM
owner I mntrad buyer of the aforementbned property on dafe aPP��n is filed.
�nature (ax+�YS fiA �nie) Oate (rtronfh. tlaY. Y�)
PddressdaulhorizedVersan (num6eranE9reaf.dh:
�'Grl i. l � C� ( �
or by IC E7.142-0.7
Date (madh. daY Y�)