Mortgage_Tepool^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
:, _—..
: FOR DEDUCTION FROM ASSESSED VALUATION
• Stata Fortn 43709IR11 / 6-09)
�,�,� , Presaibed by DeOanmeM of Loral Govemmenl Frence
File Mark
INSTRUCTIONS: �
To 6e filed in person or by mail with the CountyAUditor or Counry Recorder of the county where the property is located.
Filirg Dates: 1) Real PropeRy: Must fi/e dunng fhe year !or which the tleduction is sought. ,^f. f� �[Cryc dimr
2) Mo6ile / Manulactu�ed Homes rrot assessed as Real Praperty Must file dunng the twelve (72) months � �f � e
6efore March 31 of each year the deduction is sought.
See reverse side lor addiGonal instmcGOns and qualifirations. G IBS ,
MP�m(owrierorcont�buY?r-seeies�'�' cm�ersesid � /1
number /
L..
1, aamnt yPar
tt ra, wiiat a his / trer exxl
�� fIMIC Ofl lCCM1: 6 QIiiCRlli I�NfI I�12i Oi Bp�Qlli YIQIpIC bE�O1Y.
Name of mon�ayee or m�aact seuer /] �
l/
Addtess of nartga9ce w cantraU se0er (numbri and stree4 �Y. sbte,
� O� '� DO [� 1� V V ! RecoN �wpC�r Page nu� U
Ol
irdebce0�ss unpaid a of Alongage / ConVaC'uNebtetlnass unP� as ol Is the aPP��t Me sole
v tlate W apW�tmn I�al a eWrtaHe ox�eY'
❑ Yes ❑ No
tt owned vriN someone oNer tlun spouse. i�icata with wtnm
IS iM P�7enY N Ouesipn: MmuM Assesu-0
❑ Rea� avPeny ❑ ni?�i�aM wsses�d . . .
Name of assl9nee or oNer owner or MWer o1 rtart9a9e
Address o( assignce (number aM slreeL ciry, s+ffie, end ZIP cotle)
Dpes applifant ovm properry in any oUer If ye /I P/�() � �/�'UCJ�� � + Na Ced�Cion haen requesled on Oroperty
munryinlndana? � Ye5 ❑ No 1� 1 V– wrtentyea(! � �,e5 ❑ NO
�a �� � �
approved'c� ihe amoum oF.
20 _ I 20 _ I 20 —
Caunry
20
�Y. Y��)
20
I I We certify uMer ihe penalry of perjury that the above and foregoing infortnation is We and correc[ arM Nat ihe applinnt is a resident of Indiana aral
ovmer I contracl buVer ot the aforementioned property on date appiication is filed.
py;,on aWp�aed py CWy eze�.y�e7 pa+'�r of AtlomeY m M IC 61.1-12-0.7
Addmss ot auifmr'¢ed peaon (number a�d stree4 ciN. stafe, and LP code)
Date (rtmfh. deY.