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'°'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou sn
__ , FOR DEDUCTION FROM ASSESSED VALUATION
� Sfate Fortn 43709 (R11 / 6-09) �
�,,,� f Presaibed M DePartrtieM o( Laal Govemrtrerd Frerce
wsrRUCnoNS:
JlS�e "p�} 2010
b 6e filed in person or by mail with the CountyAUditor or County Recorder o/ Ihe counry whe2 the propeRy is located. F� �� �:
Fifing Dates: i) Real Property: Must file dunng the year for which the deduction is soughL �%�._ C�j�i dimr
2) Mo6Ae / ManuFadu2d Homes rat assessed as Real Property: Must h7e dunng the tweNe (72) months � ��
6e(oreMarch3fo(eachyeurNededucfionissayht 6�63 NGOUI�Y"
See rev e side (or addilional instnxfions end qualficafions.
MP� 1 owneror contraU - see �ejq'cf'e�u m rev1rs� site)
share of intemst?
tl'wne m 2m�d "s dAferm[ Wn that U aFP��i, uMUate belrnr.
Name W rt�atgagee or trari se4er
AEEress of mwfga9� a mntreG se0�
w ottrer awner w halEer of morD
re(numDei erM streeL dy. stete
� aPw�,� �,�, �� � a�Y oUa
�,�cy �� i�a�?
❑ Yes
D�uc�m app�aved In ihe amount
� I �
SigreL�re W Co�mbAUdttor
Nc
-o .���oa
.4deMetlnes5 unpxM as Of MMga
v Eate ol
If wme0 wiN m
•�3
unpaid as of I U Ne app6mnt tlx sde
legal a epulpde ame(.�
❑ Yes ❑ No
ahm than sPa+u. iMkate wtth whom
Dra���er NO...a� ��.......
Card i\'O. ....�.r%q/ ........
'$55,0� °°
Is ihe properry in Question: Mnua�yAtsesud
❑ � �a�v � �+�N �
20 � 20 _ � 20 _ � 20 _
s� �, �
Yes ❑ No
Date (rtqrvh. tlaY. Y��
i���
I I We certify undel iha penalry of perjury Mat tha above and toregoing intormatirn is We and cortect arid that Me applirant is a resideM of Indiana arxl
owner I contracl buyer of ihe afwemeMioned property o� date appl'rcation is filed.
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