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^'3 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
; FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Fwm 43709 (Ri1 / 609)
�' Presaibed by DepartmeM of Local Govamrtrerd Fnance
File Mark
INSTRUCTIONS:
h 6e filed in person a by mail with the Counry Auditor or Counry Recorder of the county where the property is located.
Filitg Dates: 1) Real Pmperty: Must file during the yrear fw whith fhe deduclan is soughL Co n di r
2) Mobi/e / Manufactured Homes not assessed as Real Property Must fiie dunng fhe tweNe (12) months
before March 37 0/ each year the deducfion is sought. un er
See reverse side Ior additional insWcGons and qualifications.
�, Appfinnt (ownerpq� rt buyer- see m rse siie)
Y.1 e.r .r, n� ►�c� .� IM n, p o,. n n, n.,,, .Q c.�.m.:��
X J� IS -/LJC) ' tJtJ 1•
a/ Contract iMehtedr�s unpaid as
t. ar}�t �ear �
I( rartie m �emrd's dAtgent ihan Nat W applManf, IMka[e Cebw.
m rrortgagee v mntrad seAer
^T��:..
rtnrtgage
Gr�"L��
inEeMeEness unpaid as d Is Ne eppfaant Ihe sole
legal or equilade v�vrM
❑ Yes ❑ No
sonieare dher ihan spouse, indipte wiM whan
Ad72ss M assignee (number aM sneef, my. sb1e, antl LF ' n� y� [-�� (J f�
F—Rf—(,�� VF-�1-��
Oces apptiqM ovm properry in any other If y� �� �� �
munry in IMena? ❑ ❑
Is Ne property in Question: Mm�30y A55e55eA
❑ Real ProPeKY ❑ ArmuaM Pss�ed
Has N's tleEUUion Eeen reGUesteE m P�Y
for artem Y�r! r-� . r-i .
Yes No � u res u���
rn�, Q �,�; AJA'
ducem approved in Ihe amoum of:
p7b/0- �l�'
zo zo zo' zo zu zo zo
�naMe of Camry AJlQitw Counry Date (moqf�=Y• Ye �_�`.
�� 5
I/ We certify uMer the penatty of perjury th the aDOVe foregoing irrfortnation is true and mrted arW Nat the aDP���� �s a resident of IrWiana aM
owner I contracl buyer of the af«emention property on date aPdicatlon is filed.
� ���
address w applmant
aWnrtred Oy diEy esewteO Power
Cy IC G7.142-0.7
person (num6er and streeG ci(y. sfafe. end ZlPmtle)