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'°� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou ns '
__ _ FOR DEDUCTION FROM ASSESSED VALUATION
�• State Fortn 43709 (R71 / 6-09)
� � P�esvibed by DepartmeM of Loral GmiemmeM Fumnce �
� File Mark 2010
INSTRUCTIONS:
Form ad wRh:
To be filed in person or by mail with the CounryAUditor or Counry Rew�der o� Ne county where the properry is located.
Filhg Dates: 7) Real Pmperty: Must (ile durirg fhe year for which Ihe deduction is sought ,_n Co�pjy it�
2J Mobde / Manufactured Homes not assessed as Real Property: Must fiie dunng Ne tweHe (72) months �k�� �o� �rder
befae Ma�ch 31 of each year the deduction is soughL U� �'
TOR
See reverse side for addilional instructions and quali�cafions. GI
IAmJ'xam rermnharlb���-see mrererse '
Ass�sed value af real P�D�Y %z ot
i�erff� t.amntyear
rc m. wfiat is his I Irer emG share ot intcrst?
- - - Q(1- 0�o/. - �a �{
MoRgage/ ContraG i`deWetlness unpaid as d MMgage / Can�aa'vdebteMess
Mard� i, curteM yeer deta af apP�atian �. �
tl name m 2mN a S�wn.�. �•__ ..__
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Dr�u � „'J O�
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Signa¢
I/We
a�� � � ��;ee
If ownetl wiN sarnearre
'JP roda)
W�al Ta�dig DistriaP
:OUNTVAUDROR
2�_ 20_
Caunry
numbu Page iwmbPi
��o !1�
�s d Is Ne appOrant the sde
legal «epultade owne/1
❑ Yes ❑ No
re popeny in puestion: MnuaOy AssesseE
Real PmpeAY ❑ �irt�ual�YAsse.ssed
Mas N's dedurlim Oeen reQueste0 on property
(m a�rent Y�R � Yes ❑ N
�_ �_
oate (rtrmfh. day, Y�a�
of perjury ttiat the above and foregang intormation is we and cortea arid that the appluant is a resident of Indiana and
orementioned property on date application is filed. �
/' � Date�da . / O
Pddress of authoraeE persa� (numAer arM sbeeL �}: stdfa. and LP co0e) .