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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Co 7ownship Yea,
__ . FOR DEDUCTION FROM ASSESSED VALUATION 9 2O
�.. • Slate Fortn 43709 (R71 / 6-09) EP 2
�,.,� 1 Presaibetl by Department al laml Gwemment Frence
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wsrRUCnoNS:
To be filed in person of by mail wiUr the CounryAUditw or Counry Recorder of the county where the property is located.
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F�Nrg Dates: 7 J Real Property: Must file during the year /or which the deduction is sought. GIBS '� �unry Audrtor
2) Mobde / Manufactured Homes not assessed as Real Pmperty.� Must file dunng the twelve (72) monfhs
before March 37 0! each year the deduction is soughG ❑ Counry Recorder
See raverse side 7or addifwnal instrucGons arrd qualifications. •
Ma�a�4(�mar aontrart bwrer- ue rcst�eas m reverse sidal ' .� n
IMetdi 1 qmN ypar
If rq. what is his I M
mber / legal dctaipGm Recortl number Page wmbrs
-�a-o �-�oo 0o a.ia y-oa ao ri �t �
ge / ContraG'udebtedness unpaid as of Mortgage I Contract iMebtedness unpaid as d Is ihe aOW��t Me sole
7,%���" t yeer Cate of appGntion legal w equltade owne!)
I ��f�( � O ❑ Yes ❑ No
If wmed wiN mmeone oNer than smuse. iMirate wkh whom
tl name on reard's dfierent than that o( aGP�t "cMicate belrnr.
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of
mutgagee or mno-xt se0er
w
sfate,
AAtlRSS of B55ignee (num6ei antl stree4 �Y, slate. Bnd ZIP mCe)
Dces ePdimN own property in any oNer If yes. xif:
munry in IMana? � � _
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COUNTY AI
wovem m a�estioo: a�m,aoy wa�see
�i a�oaertv ❑ a,�,��yw�ssed
MoMle Home OC 61.
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Card NO. ..�i!�g� �S
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I I We cert'rfy under ihe penalry o( perjury that the above arW foregoing infom�alion is We and cortect and that the applicant is a resident of Indiana arW
owner / mntract buyer of the aforemenlioned property on date apP����n is filed.
Sigreni eYs !utl remevwru.c.(- I.�b—�/Vrvl Date (month. daY. YmaA
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FW ' ent a0dress�of appGCant (number ard sLaet, dty, state, end ZIP code)
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Pelson authorized Gy duly esecuted Power of AttaneY or by IC G7.1-12-0.7 Date (rtronN. day, yea�
Mtlress of aWra¢ed person (numberaiN sbeef, ciry, state, anE LP code) _
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