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^'� STATEMENT OF MORTGAGE OR CON Coun Township Year ~
_ _ FOR DEDUCTION FROM ASSESSED VAL ���
.. State Form 43709 (R11 / 6-09)
�,.,� ` Presaibetl �y DeparlmeM of Loral Goremmen� Fnance
wsntucnoNS: MAY 1 3 2011 File Mark
Form fli ed '
To be �led in person w by mail wifh the CountyAuditw or Counry Recolder o/ the�u My perty is located. �
Filirg Dates: 7) Real Properry: Must fJe dunrn� Ne year (or which fhe deduction is'so�7§hL Counry Audimr
2) Mo6de / ManufaGUrcd Homes rat assessed as Real Properfy: Must fiie dunng t fw �� months
6efora March 31 of each year the deduction is�u�!� h
/ � G�gSpN COUNTY AUDI Coun Recorder
See reverse side Ior aJClRana( inshucGons aM a�s1 _ 1 _
Key
,��d��.��
Ma�di 1. tlx�errt year
�:L
r�a�e m �+�maere � �� �n�
Mort9a�e/Con�
rN 7. a�rtem
Add2ss of maMgagee or contraa seAer (number aM
Name at assi�ee or Wier owner
counry in �"
�
/
L
_.
Sig�ture a
� �
s�e(runnY" . /••�•
" / ��\\.•`d
t�`,C<�O• �\`.
9 G`��arp • �
�
- ool. s9P-�a7 "�'°�' '
of Mortgage / ContraG'v�debteOness unpaid a of
:\ Cate W appfration
i� � aii�
Is Ne appfrant the sde
legal or equitade ov�
❑ Yes ❑ NO
tt owned xiN someane other Ihan spouse. indrate with wMm
•. stafi. aM ZIP 6 ej .
• N/lal Ta�drg Distrirl?
COUNTY AUDITOR
2� 20
Is the property in Question: Mnually f�sse5xe0
❑ R�i a�oaenv � am�uras�sed
Na5 �his deduclion Eeen requesle0 on P�WertY
tar wrrent Ye� ❑ Ye5 ❑ No
20 _ � 20
I/ We ceNfy under the penalry of perjury that Ihe above arW foregoing infortnation is true and mrtect and Mat the applipnt is a resident of Indana aM
owner / mntrad buyer of the aFqremenUOneC property on date appliralion is filed.
pawre ./s!w rer➢N /1 � Date (nonfi. day, yeaA
4J 5 T
tlry, state,
of Attm�ey a Cy IC 61.142-0]
Pdtlress of aufha'ved person (num6er arM streef, cily. stdte. and ZIP mde)
oa�e (�,mm, aar. r�M