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^�,, STATEMEIvT OF iv10RTGAGE OR CONTIZ4CT (I�DEBTEDIJESS
,�',��' : FOR DEDUCTIOiv' FROiJ A�SESSED VALUAT(On " "' _ r
��� State Portn 43709 (,471 / 5-09). . �-
��'—�� rtesclbedby�epat.mar,FotLoca�Govemrz;entFlnance
INSTRUCpOh�S: �
To be /!!edln person orbymall. , �loV ' '�e Dlark
RIing Dafes: 1J RealPinpeity. Mus; be comple.=d and da:edln �e cafenda; yea; fo�w,yi„h „^,e dedodlon'ls s �y Form .. �- � ,
Must 6e filed wl;h the Co�nryAuditororGounty ftecorderof the aounty where the propertyls �y�jQ�,.CJ' , Countyqudlto�
on or before Jznuary 5 of the lmmetl(a(ely sutteeding calenda� yea� �g ^
2)Mobr7e/1f,anuiac.uredHomesnolassessedasPealPloperfy;Mecfh7ewl(htyeCountyA.vditG�o7'L�P'CO ❑t � Recortie�
. oounfyWhere the propertyfs loca(ed dudng the Lwelve (!2f mon:i;s before M,"zxJ� 3 j of each yse�;he� �
deeuction is sought
See reverse s/de fd� add/flonal Ms✓vcJons and q�a/ifica(lons. � �
AppOcan!(aw�.�o�ronhaGbvye�-saem (ACljonew;m eslde)
Chr�s�=r�nl���- �a�,..i �%,,_; < .
J J�nn�S.trr✓
Assessed vaWevf�eal propu(y as of
March 1,�rtentyear
If r,a, viAat Is his / her exaot sSare c;
I( ra,Te c.^, n�rd �s di!(emn( Ghan Ih
?f � 3''l -�cofl -c5o �. �,3 5 - 0
Mortyage / Co�tract Indebtsdn_ss uopald as oF
fl,arGh 1, cv;re�tyea[ '
. �� m gagae or conVaci uM! (number and sG
P.o. ��,x Ig °1 'ti„
Na.�e o, azs�gnee of olher oymaf or �olde: o/ mortgage
Address�o(assignee (numberandsbeeC �Ity, rfale, and
- Does app�;.ant owri pmperty N any �.
covnry In Indlana7
� Yes
In Ihe
20
20
IiG
r
;'F (/�n.��
I(yes, whaf rnunty7
20_ I 20�
Mo�tyace / Co�.��; �nd/eb_teCnesz unpzid as o(
data c: appII�LI _✓1 DO VO .
N{ �
f 'J l
Kilh so.Tmne oNar an spouse, lodlcata u1� w
��6�
20 __
20
In questlon:
erry � q
ov+�an I
❑ �o
� i.
:tea vn pmperty,
i
Yes ❑ ,Vo
20 .
Counly � �ale(mon;h,pey, yeaQ
I/ W ar'Jfy und r Ih p n ly o p �ury Nat th ah a d t r g I�g m'n„ne�on Is tue and coRZCt and that the applicant is a�resident o; Indiana
owne, / contract buyer of the aforemenUoned prope ,ry on date appllcaUOn Is fi�ed. �
iqa�e�(otyier's/u/ln e4 � '
. FW reside, /addresi vl a pcant (nv '
w,
Person au oAze by duly esaMaC PvWer
.Addresaofaulho,-kedpvson (num6eranc
ciry, slafa, andLP
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