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"^n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE� n ship vear
_ FOR DEDUCTION FROM ASSESSED VALUATION
State Farm C3709 (R71 / 6-09) L •
�' PresaiOed Gy DepaNre�rt at Loral Gwemmer2 Firance �l /
'le Mark
wsrRUCnoNS: DEC 2 0 F���
To 6e filed in person w by maii wiM the CounryAUditor or Counry RecoNer o/ the counry where the property is located.
Fi7ing Dates: i) Real Properry: Must file during the }rear fir which the deduction is soughG � � County Audimr
2) MobBe / Manufectured Homes rwt assessed as Real Properfy. Musf file dunng the twelve (12j,�n,"9�5, �� �nry Recorder
betae MaicA 31 0/ each ysar the deduction is sought. � G
See reverse side foradditional inshuctfons arM qualifications. GI9SQN CC�UNTY ..
n�a � a re� vorenr es a
MarU 1, amnt yUr
�( Iq. W�Id� 6 �16 /:IP.f Ei2Ci 5�12lB Oi �IIiPl25Ii
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r/ legal drsaiption Recortf numhu Page number
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Mortqage / Contract IndehteEness unpaitl az af Mor�qage / Con�W iMe6ted�ss unpaiA as d Is Ne a0d�t Me sde
Mamh 1, artent year date of appl'ication legal w epuRade ow�mll
O D ❑ Y� ❑ No
If awned with someone atlrer ihan spouse, 4Mirate with whwn
tt name m n,md is Oiffemnt Nan tlat ot aGP��i. 6Mifate bebw:
mortg2gee a mntrarl se0er p � �
� ��..v�.�
Add�ess of nnrtgagrx or mntra�Y se�er (numbrJ and streef, ciry. 9ate. aM LP coda)
Name ot assignee a oNer ovmer or hdder M mortgage
AdaRSS of essignee (nUmOBreM Sfree4 ury sle:e, entl LP cotle)
PT sw 8-a-�d ,�YB��
Dces appliraM ovm yoperty in any oNer IF yrs. what munt7/1 W�at Tarir
munty in Indmna? r-i .. r-i ..
20 20
iatim W Caunb nuditcr
/ We certify u the pen
rwner / mntra uyer of th
miure (owners NO name)
�
COUNTYAUDROR
20 20 _ 20 _
Counry
Is C�e property in puestim: Mmia�y Asessed
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D►�a �ve►• •NO .. .. ... ... . . .
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Card i�70. ......7��b.......
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Data (rtwnth.
the above and foregoing infortnaGan is We and mrrect and that Ne applipnt is a resident o( Indiana arW
property on date appiicatlon is filed.
Daie (monfh. daY. Y��
state, eM LP mCa)
� d� ��� � �� �, � �� �,.,-,z-0.�
AdAress of aNhor'vEC person (number aM sbeet aY. sbte.
�er,.c� I ( � 7'�4 [ I O
76 7d
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