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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ = FOR OEDUCTION FROM ASSESSED VALUATION
• State Form 43709 (R71 / 609)
� � PRSfiiDed M�rt+nent W LOUI GovemnroM Fnente
ie a
wsrRUCnoNS:
TO 6e filed in person w 6y mail with (he CountyAUditor or Counry Recorder o/ Ihe counry whe2 the property is located. 2� 09
Filing Dates: 7) Real Property: Must file dunrg the year for which the deduction is soughf. � County Auditor
2J Mob�7e / Manu/actured Homes rat assessed as Real Properly Mus! file durirg the hveNe (12) months
before March 37 07 eacA year Ne deduction is sought ��q�, Recorder
See reverse �de 7or additional insfructions and qual�catrons (;IRRnN Cnl INT V AUDITOR
� Ap�nm,(a r w mntraFt buyer- see i�3lrirtions verse side) _
w �o � � m —
Asseaed rWUe d real pov�' az W Mortnage / Contract u
Me�di 1, arrem year Mamh 1, artent yeer
If Iq, what a his! Mr P�ac[ share Of interest?
tt name m remtl is tliRerent ihan that of appfi�an4 hMifate bebw:
of rt�wcgagec «conirad seller
s ot mat9a9ce w contraa seU
af assignea w oNrl owner w Y
Oces epplimnt o.m property in any oNer
munry in IMena? ❑ Yes
Deductian aOWa'ed u� Ihe
20 _
Sig�Wre dCamryAUdimr
I/ We certify under the
owner I contr�ct buyer
revtlem
r�
snae4 ��x uare.
city, S18te, antl LP mde)
��,�.�����
❑ No
/- �. �o%s -C�G v
ness unpaid as ot Mortgage / ConnaU rcWi
date of app6otion /
If awned wiM someorie other than
AUDROR
ness unpaiC as d Is Ihe ePPr�^t Me sok
legal w equitade ameYl
❑ Yes ❑ No
ue, indirate wBh whom
fe property in a�g�: �nually Assesud
Real Property ❑ Mnually Assessed
d�.U�......
Dra��er \0........
��� �.........
�1,�a �o. .... .
. .� I I (.�� �
20 20 20 2Q 2[1 _ 20 _
Counry Date (monfi. EaY Y��
mnalty of perjury that lhe above aM foregoing intortnation is We and correct and Nat ihe appliran[ is a resident of IrWiana aM
�f the�bremenhpr}�Cproperty on date application is filed.
Date (rtmfh, day, yea�
afy, state, 3M ZIP wtle)
�/�,..� �vf .��
Adtlress of aNhvtrsd person (num6er aM uree; rif}: state, anO