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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R71 / 6-09)
ti ! Presaibetl M ��P��M o1 Locai Govemment Fuunce
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INSTRUCTIONS: wM
To be filed in person or by mail with (he CounryAUditor w Counry Recorder of the oounty where the property is lacated. ��� 1' Z ��0
Filirg Dates: 7J Real Property: Must file dunrg the year /or which Ihe deducfion is soughL � Counry Audimr �.
2) Mo6de / Manu/actured Homes not assessed as Real Property. Must file dunng tha tweHe (12J months
6e/ae March 37 0/ each year the deduction is soughL Ceu Recorde�
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See2versasideforadditionalinstructionsandqualifications. f �g�w,��'f�,g�7p�TYAH81T6R
Aoafran� fownai - "�^" buver- see iestri-2wss m re�vse vdel � �
Tad� Rey rwmber / tlesvipGm Remrtl numbrl Page numbrl
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AssrssM vdhie d� property as of MoRgage/ Contrau 4de6tedness unpxitl as d Mangage / Contraa'viEebteMess �mGaiO a d Is Me ePP��t the sde
Mamh 1, anaR year Mar� 1, oi Eate of appGraWn legal w eQUitade ownell
7 � ❑ Yes ❑ No
It m. what Is his I her eraa share ot interest? If awned wiN someo� otlix ihan spouse. in9rate WN whan
tl�me m iemtl "s QAferen� Man Nat W app�nt trMirate Debw Is Ne Pr�RY m 4�xs6are Mm�aOy Assessed
� �eal Pfoperl�' ❑ Anrlua�y Asses�
Modle Fiart�e fIC Gt.7-;
Name W rtmrt�ee ar contrad
(numbrJ aM.wee1 �: atam, erN LP rode)
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Adtlress of assgnee (numbar entl saeeL �: s+ete, an0 Z!P oode)
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Oces aPplitant avm property in eny oNer It yes, wlu
murLLy m Ind'ana? I-'1 .,_ _ f'l .�_
D�uWOn app(oveC in 1tre amount at
20 20 _ N1
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COUNTYAUDROR
20 _ � 20 _
Caunry
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I/ We certfy ulde�jihe penalty of perjury p�ai the above and foregoing information is true and mrrect arM Nat the apptirant is a resident of Indiana aM
ovmer / contraq buyer of the afaemerrtw��ed property on date application is filed.
ina�ue (owrreCs hNname) n � � Data (manN. daY•Y��
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Adtl2ss of auttrof'ved persa� (numhe� aM sbeet �+ry, sbfe.
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