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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Yeat
.y.._,
: FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R71 / 6-09)
S,w. � P�esaibeC by DeP��N al Loml GoremnreM France
File Mark
wsraucnorvs:
To be filed in person or by mail with fhe CountyAUditor or Counry Recorder o/ tAe counry where fhe pmperty is located.
Fi7mg Dates: 7J Real Properry: Musf hle during the year for which the deduction is sough[. ry q���
2) Mo6ile /Manufactured Homes rrot assessed as Real Property: Must fi7e dunng Me tweNe (12) montM1s
be(ore March 31 of each year Me deduction is sought. ❑ � e��
SeereversesideforaddiGonalinsfructionsarMqualifications. 1 GIBS TYAUDITOR
�MW� (o- racorivar�byxer-seerestrirytionswy�erersesidel /l o .
� - - - 'f- GU - �o � �f3 - o �
ed ralue oF 2al P�P�Y as of I Mwt9a9e / Contrati indehtetl�ress unpaiC as of Mwigage I Contrac[
1, amml ym Marrli 1, wr2nt Y� Eate of appGnUm
tt m, what a his / hu exaU share ot intrlest?
If riartre m mmtl a dilterent Ihan ihat W app6cant, trNipte bekw.
Name of rtrcxtgagce or mntra<Y seller r
�
A�dress W rtidt9a9ce w contraa se0er (nwribri and sbce{ �y, state,
Name af assignee or other owner or hdAer ol mortgage
Atltlress of assignee (number aM street �}: s+ate, and ZIP cotle)
Ooes appluam rnvn property in any ONer It yes. what to
counry in Ind'gna?
❑ Yes ❑ No
Deduction appiovcA in Ne amount of:
It owned vriN sornearie
COUNTYAUDROR
— ��
Is Ihe eppGwtl Ne sde
legal w eQUitade owne/1
❑ Yes ❑ No
iMicate with wMm
Is tlre V�PenY in Vuestion: MnuaOy Assessed
❑ Real Property ❑ MnUally Assessed
/� c
s inis eeaudlori Eeen reQUestea m propelty
wrteM yea(.�
❑ Yes ❑ No
20 _ 20 2q 20 � �_ 1_(l CQ/`�C`, _
O�Wc�.x �p�7p.
�nature of Cartiry AW imr G
Dra�r�er i�'O.. �OI�.........
I/ We certi(y under Ue penalty of perjury that the above arW foregoing infomiat a95a ana and
wner I contracl buyer ot Ne afotemerrtioned property on date applinlion is filE T
���n�� � Card \O. ..... ............
Y � iC � � �GB, ib6.�9' _
II ' ent address of nt (numEer antl sLeet, ciry, slate, and ZIP oode) _ .
J V IN • -i�— �k
autlror¢etl Ey dtdy exewted
by IC G1.142-0.7
person lnumberantlsveef.dry.state.andZlPmde)