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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun T ip Y ar
ir`—'
s FOR DEDUCTION FROM ASSESSED VALUATION
� � S�ate Fortn G3709IR71 / 609)
S PresaibeE by DepartmeM W Lad Govemment Fu�ance
°" File Mark
�srRUCnorvs: -"—
Fortn fJ viRFi:
To 6e filed in person w by mail with fhe CountyAvditor or Counry RecoNer of the county where !he property is located. ,C�,o
Filirg Dates: 7) Real Properry: Must fde during the year /w whirh rhe tleduction is soughG G BS�Cvy . '�8
2) Mobde / Manufectured Homes rat assessed as Real Property: Must file dunng the tweNe (72) months Counry Recorder �
belore March 37 of each year ihe deduction is sought.
See reverse side for addrfnonal insUucUons arM qualfications.
whai is his / her erar2 share Of inteRSl?
If furtre an reooN is tlittemnl Nan Nat
rlame a rrwrteasee «omvaa
AAeress ot mort9a9ee «cantraa se�er
—.� � - �.� -
Mortpage / Conbaa'udehtedn�
March 1, artentyeer
ant, i�Wifate bebw
3
:r anr/ streeG �y. state. aM ZIP cod�
owner or hdtler of mortgage
assignee (numDer and atreef, ary, state.
Dces epD���nt ovm property in any olher I If yes, wiiat muntyl
counryinlMiana? n ., n .�
oee�mori
20 - I 20
Sig`ad�re d
�_
�• OJ��- Qo�
as W Alongage I Contra
date of eppliption
it owned wi� somewre othu tlan
/7 �d - /'
bMat Ta�dng D'atric
�uNrvnuoROa
20 20
Record numEer Page
U �� � .
unpaid as d Is Ne eGP�
legal w eWil
�i7
Yes LI No
Is tl�e property in QuesGnc NinuaOy Assessed
CXRealPfopefty ❑MnuallyASSessed
i(' Mo6de Home (IC 61.
�
D�-�,;���-�:'o.:��!a�:;:..�:..
Card NO. ...'.� ri�?�.........
�13��. �a73.ocn.°°•
20 _ � 20
Date (rtron(h, daY.
I/ We certlry under the penalry ot perjury Ihat the above arW foregoing intormalirn is we and cortecl arM that the appiirant is a resident of Indiana aM
owner I conVact buyer of the aforementioned property on date application is filed.
..,�rar,,,.,.e.t xm.umni Date (monfi, daY. Ma+)
� �
FWI resiCent radtlfess
� � L
Person
afreef, dty, state, antl
Power of Attomey or by
yuthomy�0 person (num0er arid sbeel, ciry, sfate, erM ZIP ootle)
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