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""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C n T n i ear
� FOR DEDUCTION FROM ASSESSED VALUATION
•`�'l'StateFam<3709(R10/11-08) J N 0 9 2009
Presaibed bY �M�ent o( Lorai GovammeM Firenm
INSTRUCTIONS: �File M�(k�
To 6e filetl in person or 6y med with the CounfyAWitor d Ure county where the poperty is Mcafed. a"' �
Alirg Dates: 1J Reel Property: Musf file during the year lor which the deduction is sovght. (:�Rcn � �
2) Mo6de / ManufactureO Homes rrof essessed as Real Property. Must fde durng fhe tweAre (12J mdR11S'Dbi�M�ii�iTJ �o�T�
Ure aeducfion is saught.
See reverse side for adddional insWdions arM 4�f"rficafions
�a �� mr�i v�arm � d
i, mrem yea
rt,a� � na i nm enaa sn� d��resn
Pddress d mongapee ar
/s�m/��e_vase mde) /n(
i LC'�t� . �-t '
r/ lapal dewipfun Record number Pape number
8.,3�-�n3-000, a38_oo � �
Mo�gage! Contrad rcde6tednea unpaid as d Mortgapa / Contad indebledness unEeid as d Is ihe app&aN O�e sde
March 7. wrteN year . dale o( appfimtion legal a equitable awne(t
OD� ❑ Yes ❑ No
N owned with someo(re dher ihan sPa�. i�icata wiUi wfvn
Nama d azsignea or otl�ar wmar or hdder d matgape
PdEress af aaignea (�wmbar antl sbeef. �dl: sbfu.
Does appfiont awn proparty in a�ry dher
Caunly in IMmre?
❑ Yes ❑ No
Oeductian appmved in Ne amouM d:
20
Signature d Courity Auditor
20 _
�/'
I
�
H Yes. what cpmy?
h Ne G�WaM in G�sfmn: MnuaN' AsSes.%E
�Rea�Fraperty QnnnualryASSessee
Madle Hwne (IC G1
Has Vus aeauaan Deen ieVUestea on D�opanY
for airreM yeaR ❑ �
❑ Yes
C(
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C:If'C� 1�'�, ,
L �Y• Y�I
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I/ We certi(y under ihe penalry oVperjury that thefabove and fwegoifg mfortnatbn is true ana w.. _
owner / mnGad buyer of Ne aforementioned property on Aate appliption is file0.
$ignalu ( shdlnartro)
�Full I addres d� ad sbeet. c�ty sbtri, anC LP co0 )
�`� �r�?a��� �4u,� l/l� �%(�-��
Person ault�oraeE by AuN esaaile0 Power of Nlomey w 6y IC 6-7.1-12-0.]
AdAress d aNhaized person (nunDOr and s4cot. dfy, ffife, and LP coCt)
a resident of Ind'afa aM
h. daY, M�