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'°n STATEMENT OF MORTGAGE OR CONTR� I ID�BT�QfI� Coun Township Year
__ ; FOR DEDUCTION FROM ASSESSED VAL�IAT�pr� ��
Stata Fortn 43709 (R77 / 6-09)
� w. T PresaiGetl by DePa�rq of L.oml GovemmeM Frence
JAN 2 4 2012 FileMark
NsraucnoNS:
_�
fo 6e fi7ed in person or 6y mail with !he CounfyAUditor or County Recade� of the� �tmt;��WhE�s�tlfe property is bcated. F� ���
Filirg Dates: i) Real Pmperty: Must fiie durirrg the year for which the deduc�t1iyon is sougeAL vp�h � [1 � County Auditor
2i be/o,re March 3 0! � yearthetdeduction is mugM �G�BSON CUU�Y Au�K 2) monfhs � �nry Recorder
See reve�side lw additional instructioCs and oualifrcafions. i
Appfim cont� r� see m reverse siCe) _-. '
li:�l
If ro, what Is his / her
�,�-
A1or(qage /
Mar� 7. a
u nartre m recoN is dirterent than ihat o( aPP���. �dicate Debvr
Nartre of mortgagee or contta<1 seller
Mdress of rtnrt92gce or contraa seuer (number and sbee4 �:
a other awner or
st�ee( aly, slate, antl LIP co0e)
Does applinnt own property in any W
counryinlMana? ❑ Y�
aion e�v� m me ama,�� oe
2�_ 20_
_,do-bo�. �9�-o�y "Loi� 5 saa
Iness unpaitl as W Mwtgage ! Conbact indebtedness unpaiC as d Is ihe applircant Ne sde
/yr�� Cate of appGration legal or epukaHe owne(!
'L�/ V ❑ Yw ❑ No
If owned wiN someorre Wher Ihan spouse. iMipte wifh whom
Drawcr NO.. ��('.........
Card NO. .. � � � 0......
�y,D�.tSI)
Caunry
Is �he ProPeM in questian: MnuaOyltsses.ud
❑ Real PfoPertY ❑ Armualy Asussed
uia? I Has Nis deduaion been requesteE m PropenY
rw a�,�n y�r.
❑ Yes ❑ No
20 _ 20 20
/l ../� Date (monfA� daY, Yee�
I I We cert'rfy under ihe penalry o( perjiFy that lhe above �(oregoing infortnalion is true and cortect arW Nat the applipnt is a resident ot Indiana a�
amer I contrau buYer of the aforementioned property on ate appliqetion is filed.
and sheet a+Y,
AtlC�.s d autharzetl pe�son (number aM stree; riry, state, ar+d LP mde)
trate (rtronth, daY. Ysa�
yea�