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"•� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
,_ FOR DEDUCTION FROM ASSESSED VALUATION �
• Stata Fwm 43709 (R71 I6-09) ��
� / Presaibed by DepaNnenl af Lasl Govemment Finance
�� �� File Mark
INSTRUCTIONS: �
To be fifed in person a by mad wiN �he Coun Auditw or Coun Recorder o( the coun where the F �� ��
ry N b v�aenr is rocared.
Frtirg Dates: 1) Real Property: Must file during fhe year for which the deduction is saught Coun AuAitw
2J Mo6Ae / Manufadured Homes not essessed as Real Property: Must file dunng the hvehre (12) months ry
be(ore March 31 o/each year the deduction is soughG County Recorder
See reversa side for additbnal instructions aiM qual�cations.
MP��i (ow�6�'Orcontract buyer eea msLir110Rs m reverse�tid ^. // n n .
Assessed rahie dreal yapeny as o( I MorWage / Cantract'v
Marh 1. anan ycar Mamh 7. airtent yeer
�
.f no. wha� Is tri5 / icer Cud Shara of intPrat?
If name m reartl's dRtnmt Uan ttat o( app6cani, indifate hetrr.
r�ame m mortaasee « conrraa seuer\drC/.Q �( .�F�OQ'
Address ot nwrtga9ee w wntrad sWer (narnbar eM sLeet, cily, slate. aM i
Nartre o1 assignee or oNer ovmer or halder of morigage
ACCress of asagnee (number antl stree; ray, state. antl LP coEe)
Does app6rvnt own poperty in any other If yes, what county?
�,ur �� i�ae�� r, .. r, ..
itre amoun[ of.
20 I 20
I/ We certify under Ne penalry
owner / wntract buyer of ihe a
I�
Eate ot appGtltion
H owned wiN samrone oi7w1 than
Y`/hal
COUNTYAUDROR
Record number Page nu �
Q
bted�ss unpeid as of Is Ne eppGmnt tha sole
�gal or equilade oxneR
❑ Yes ❑ No
SW�. YlGltata wlfh Wtqm
6 tlre propelty in 7uatim: MnuaAY Ass�sed
❑ Real RoPeKY ❑ A!?n!allY A�sed . . _.
aoll ' 813
� P�Y
��,;u� ❑
20 _ 20 20 _ 20 _ 20 _
Caunry Date (imnt�. daY• Y��
� e and foregoing information is We and wrte�Y arW Nat the applitant is a resident of Indiara arW
rty on date appliration is fiied.
PW resident atldrass ol applircant (numberan0 sLeef, dty, state, anA LP mtle)
)C /0� S, �✓ed•i .Dr, /�vv/�SOsJ�� _Z�t! y7G 39
Person autMr'¢ed �y duty execuced Pawer of AtmmeY a bY IC F7.1-72-0.7
Pddress ot autl�or'¢ed persm (nurtWerarM sbee4 �y. sbta. arM ZlPmde) .