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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE S Coun Tawnship Year
_. FOR DEDUCTION FROM ASSESSED VALUATION
Sta[e Farm d3709 (Rii / 6-09)
�,�,� ` PresmLad �y DepartmeM af L�I Govemment Fuwce
File Mark
INSTRUCTIONS:
b be filed in person or by mail wifh Ihe Cqunry Audifor w Counry Recorder o1 the county where Ihe property is bcated.
Fitiny Dates: 1) Real PropeRy: Must fJe durirg the year for which fhe deduction is sought
2) Mob�7e / Manufactured Homes nof assessed as Real PropeRy Must file dunrg the hvehre (12) months
6efora March 31 of each yeer Ne deduction is sayh[.
See reverse side tor additional inshuctior�end qualifications.
AppGOnt ( or cmtraG buyer"sqe re m rewm side)
�ed raWe d real paperry as ot
1, armnt year
ro, what Is his I hu e>act share of interesf?
n iw,�e «� remra
�mrc�ayee «�ono-aa
Counry Auditor
s I k9a1 'ption RecoN numEer Page numbrl
- a_ �40. a_ o� a�� d �3b
Mortpage/ Cantraa irdeD ness unpaid es af Mongage I Con ebieCnass unpaiE as d Is Ihe eppBrant Me sde
Mar� i, wrrertl Y� tlate of aPP�/ �❑�e ❑ ON
!f: 3 o v�;
tt owne0 wiN someo� oCwl ihan spwsa, 4dicata wtth wfnm
owner w halder of mortgage
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Adtlress oi assignce (nurt�6er erd sdee4 �y. s0i�e. end ZIP code)
Oces epplimN ovm property in any oNer
munty in Ind'ana? f'l .,_'
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I/ We certify urWu Ihe penalry ot perjury that ihe above and foregoing infortnation is true and cortec[ ar�d that Ne appliqnt is a resident of IrWiana and
owner f mntrad buyer of fhe aforementioned property on date application is filed.
Sipfanue o�neY: fu0pame) _ Date (nnntli. daY.Y��)
x - 5�0
ezewteE Powv d AOCrt�ey or by IC 67.7-12-0.7
Add�ea of aWiat"ve� pe�mn (numbe� aM sneet �: sfefe.
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