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"'r STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ : FOR DEDUCTION FROM ASSESSED VALUATION
y Stata Form d3709 (R11 / 6-09)
�' w. l PreSaiOed M�G��M af Lnml Govemmenl F�ance ,
Fil M rk
INSTRUCTIONS:
Fortn filed with:
To be filed in person w by mail vrifh the CountyAuditw or Counry Reco,der o/ the county where fhe property is located. c C p 2 8% 0�9
FiNng Dates: 1 J Real Property: Must �Je during the year for which fha deduction is sought � � J �unYy ditw
2) Mobde / Manufactmed Homes not assessed as Real Properly Must h7e dunng the hveHe (72) months
beto�e March 31 of each year Ne deduction is soughG ❑ County Recardu
ync� �,09 �_ �,r
See 2verse side for addiLOnal instructbns end qualilcafions. 9� a '"/J � /�
C z�e�
�istr'v1 / ey numCer / legal desaiption Retortf number Page numEer
6 , a_/O/—�00�$ Ss-C�1-�i O .3S
eC vabie af rral p�eny as d Mortgage / Conbact intlebte0ness unpaid a ot Morigage I Con�aG bmdebtetln�s unpai0 a d Is Ihe apd�t Ne sole
7, artent year Ma� 7, wrteirt yrar data o( appGcation legal w eWi1a61e wmeY?
�%/1 n/i n Yes n No
It no, what is his! tcer ezaG share of inferest?
tt narne m remrtl's tliRerent Nan ihat ol appfranl i�Minte be
Nartre af rtnrtgagee or mntrarl seBer � �
�
ACdrea of rtartgagee or mntraa seAer (n r and slree; u
Name of assignee or oNu owner or hoWer of mortgage
AdCresS of assi9tree (num0ei end sLee4 �Y, s+ete. ard LP a
Dces eppiimnt wm property in any other If yes.
munry in Intlana?
❑ Yes ❑ No
Oeduaion approved in ihe amount oE
���
Sig�ature ot CounN Autliwr
I / We certrfy
ownerlcon4
� FW revEent aEdress If ap
Person auCip¢etl Oy tlWy
stafi. eM LP rode)
r�
perty in QuesUOn: MnuaM Assesud
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naaie � nc s
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-(� (J E L L y PI
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COUNTY AUDITi
I
20 20
20 � 20
that the above and foregoing infwmation is We and mrrec[ arW Nat Ne applipnt is a resident of Indiana aM
ned property on date application is filed.
/II / � . � Date (month� daY. Yea�)
tlty, state, and
Address of authomed person (number arM sbeef, dry, stafe, an0 LP mde)
Date (monfh. daY. Y�/)
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