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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
__ ; FOR DEDUCTION FROM ASSESSED VALUATION �
Sfate Fortn 43709 (R71 / 6-W) '
S � Presmbed by DepaM�erR of Lacal Govemment Fnanca
�'NSTRUCTIONS: ; � ��
To be filed in person w by mail wifh the CountyAUditor or Counry Recnrder of the aounty where fhe property i t
Fdrrg Dates: 7) Real Properry: Must fJe duriig the }rear /or which fhe deduction is soughi.
2) Mobde / Manufactured Homes not assessed as Real Pruperty Mtist file during the twelve (12J montF�e CB
befae Ma/ch 37 0( each year Ne deduction is sought � 1" L
See reverse side (or adddional instmclions and qualifications. C�
AppBrant (owner or mn0ajlbq�er see �e.vrctlons m reye¢e si7e) �(\ , ,(") � .. n
m vaWe ot rnal przpeny as
7, amni year
If no, what 6 ha ! Irer e>aG
/
It name m remd is 611emnt Nan Nat of applkanl, uMinte Geb�r.
Name ot mwtpagee or mntracl selier
rtiortgagce n
mortgage
>- �I. �33-�
unpaid as U MMgage / CmvafY
� date of application
ray, sfafe, eMZlPCOde)
Address of assignce (number aM street tlry, slate, arM ZIP mEe)
wes apqrcam own properry m any omer i� yes. wnaz couruyr _ i w�d..
muMy in Ind'gna? - -
❑ Yes ❑ Ni
za i zo
5 �'�CounryAuditor
Counry Remrder
of Is I�e applkani the sole
leg3� d epuitade ovmeR
❑ Yes ❑ No
wiM someone ather than spouse. iMrcate wM vAnm
�1.'d,......
Di•a���cr NO.......
�3y1 ..
Card NO . ..................
.
�p� � .�
I I We certi(y ufWer ihe penalry of perjury Mat Ne above anE foregoing infortna
owner I mntract buyer of ihe afore enboned property on date appliration is fil�
��aNre ( e rame) '
Y �.zr • �-'^—*-�
r� ent atltlressAl apP;pnt ( .�a `streef, �ry, stafe. ,` P oode�
Persori auUqraed Dy d�dy ezecvted Power olAROmey w by IC 61.1-12-0.7
per5pn (numGBr arM Sbee(. p1y. Sbfe. an0 ZIP Cotle)
Is Ne property in Questnn: MnuaOy Assesse0
❑ Rea� afopero ❑ %�^�r�
Has Na tletludmn Eeen requestetl on propnty
for a�2nt Yea(? ❑ Yes
❑ No
20 � 20
is Vue and correa and that Ne applinnt is a resident of Indiana and
Date (nmfi, day, yea�
Date imonN. daY. Ysa�