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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
_ ry : FOR DEDUCTION FROM ASSESSED VALUATION
• Slate Form 43709IR11 / 6-09) �
�' � Fresmbed q oepartmem w tnd Govemment Finance '
ie a
wsraucnoNS:
To 6e hled in person or by mail with !he County AWitor o� Counry Recorder o! the county where the pioperty is located. F �
Fi/irg Dates: 1) Real Property: Must file durirg the year for which the deduction is sought. Counry Audrtor
2J Mobde / Manufectured Homes rwt assessed as Real Property Must file dunng the fweAre (72) months C�.
before March 37 of each year Ne deduction is sought. � Recorder
See reverse side for addiLOnal insfrucflons arM qualifications. - C
AGPfxa��(c�ronfrdrl6uyer-see�estrir�on.�a'reverseside) 'i
m remrE's QiSe�mt than ihat of app�an4 u�dxate Delow:
Nartre ol rrort9a9ee or cmtraa seller
�''r—��'�7
Reco�d numDer
az
rc ameC with someone oNU than spouse, iridirate with wMrn
I
u
Nameolzssi�Feawa�'__—_____`_'__� . . .
�a�o,��, m�"RGAREr m m�,-uy ---
�eo����a �61�0—�5�1 �
mmy i� �ndana? i
De�uctlon epp�oved i
20 _ 20
Sigriawre of CounNAWimr
�
20 _
I/ We certiy under the penalry of perjury that Ne above arW foreguing intort
vaper I contract buyer of the aforemerrooned property on date application is
street
by IC ^1,2-0.Z
person (number antl sbee4 �y, sfat&
eQUitade avrtwl?
] Yes ❑ No
IS C�e DroOeRY in VuestiOn: MnueP/ Assessed
❑ Reai a�openy ❑ a,nn�any w�
20 _ � 20 _
Date (rtnNh. daY. Y��
��
❑ No
r�
is We and cortect aM that the applicant is a resident of IrWiana arM