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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun'
__ FOR DEDUCTION FROM ASSESSED VALUATiON
�• State Fwm C3709 (R71 / 6-09)
�' ,,,, � PresaibeC by DePertme^� a1 Lad GovemmeM Finance
WSTRUCTIONS:
To be filed in person w 6y mail wifh the CountyAuditor w Counry Recorder o/ fhe counry where the poperty is bca .
Filing Dates: 1) Real Pmperry: Must file durirg the }rear fiu which the deducLOn is sought.
2) Mobde / Manufectured Homes irot assessed as Real Pruperty Must fiie dunrg the fwelve (12) months
6etora March 31 of each year Ne deduction is sought.
Sea reverse side for adUitional instrucfFons and qualifcations.
AodraN (owner_crmitrae DuYer�,ree resnirb'ons � re`e�se sipe) �%
'�L/ �I/���I Q��/1
, . r-_.
If no. whal is his I lrer ezaG share Of intrlest?
If fwne m ramtl "s ddturnt Man thai of appOCan1. u�tli�ate Debw'
Name of rtnrtgagee or trntract seller •
Pddtcsv of mortga9ee or conUa�i se�er (n1xn r et �l: state.
Name o1 assignee w oMer wmer or hdder M rtprtgaga
Pdtlmss W aaignce (numher erd s+reet �: s0�te. and ZIP mCe)
Does ePpli�nt am pmperty i� any oNer I It yes, what munt7/�
munryinlna'ana? n ., n .�
`.�:
of
�— I �
7— VOf / 1 vl vi
page / ConTe�t uWe6teenes un0� as d
�aP��, �/�GL'�D
somepne other than spause. Gdicate xtN v
Counry Auditw
�6k�lRecorder
a equitade m�+w1!
❑ Yes ❑ No
�is I(M P�GenY in Gu�On: Nwia9Y Atse55ed
hCl � �PeRY ❑ %�!!�M �
W�al Te�mg �7 Has Ih's detlumm Deen reGUrsteG an properiy
tm artem Y�r' � Yes ❑ No
Dra�ver i\'p� D1 4�
Card i\'O. ..y�L.l �—
.�..... �
sre�awre w c�+n �� . .. iar r��
� I I We certHy urder Ne penalry of perjury Mat the above anC fwegoing infortnalion is We and cortect ard ihat Ne applimn[ is a resident ot Iridiana aM
ovmer I contrac] buyer of the afaementioned property wi date appiiqtion is fiied.
� fq (owne/s hA � Date (rtiu�rth, danY. yse�
—l� �
� FWI r�iEent aEtl'es,p\t� nt (numDer enC antl Z/P code) T
� V . \ �-i— �7 �
auuior"¢ea ev a�ev ezeartea rowrJ m ammer w M�C 6ti-tz�.7 . oate (mmm. Oer• r�
persm (numberaM sbeeL dry: sb[9.