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"a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
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• FOR DEDUCTION FROM ASSESSED VALUATION
Slate Fwm 43709 (R71 / 6-09)
�' 1 P2saiEeC by Departrtierd of Lual Govemrtrenl Frence
� File Mark
INSTRUCTIONS:
To be filed in F ��N:
person w by mail with the CounryAUdiror or Counry Recorder o! the county where the property is located.
Filirg Dates: 1) Real Property: Must file durirg the year for which the deduclion is soughL �y ��
2J Mo6de / Manufactured Homes rqt assessed as Real Property: Must file dunrg the (welve (12) months
before March 37 of each year fhe deduclion is soughf. ❑ Cou^tY Recordu
See reverse s�e /or adCitional insfructions arM 4ualificateons.
I Aoo&am !� armtrtl6uver- see msMi�dw�s u�i��.xrse vtlel � C` 1.,,. �
Aswssed vahre d rnal q$erty a! of
Marc3� 7, ammt S� 1
n oo. �c s n� i n�r e=aa �re m�c��n
It �nie m recotd is tliRe2nt Wn Nat M aPpl
Name of rtwrtgagee or mntract seller
r��1f�{�� /DO�oo✓ •Ya3-aa?����/
e/ Contracl "uWebtedness UnpaiO az of Mortgage I Convad'mCebtedness unpaid as d
. wr�aj yegr �,A date of appGfatian
Address of nnrtgagee a cantract uller (numbrl and sLee; crty,
Nanre af assignee w ottrel awner
SUee(
C:�
❑ Yes ❑ No
with someone aher ttun spouse. ind'axte wNh whmn
15 U�e P�Pe+b in Gue50on: Mnu2�Y As5e55eC
❑ Rea� ProveKV ❑ �^^�N�
linnt own property in anY oNer � Has �h¢ dedudion been requesteE m Droperty
IMiana? � forwrtentyeaR � yes ❑ No
❑ Yes
llra�t�er NO...... �� 1.......
Deduction appro+eE ui Ne amount of: a Ssg
Card NO . .............
........
� �_ ° ��$;D�D �° �°—
Sigrenne of Counb AuOMr Caunry Date (monlh. day, ar)
C • d�- �l
1 I We certlfy u�er Ne penal of perjury e above arid foregoing infortnalion is We and cortecl arW Nat Me aDPlipnt is a resident of Indiana aM
owner I contract buyer of Ne aforemention rry on date application is filed.
a
o(AttaneY a N' �C
Pdtlress of autl�d¢td person (number a�M sbeet dry. s(ate. aM
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