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^�n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
• FOR DEDUCTION FROM ASSESSED VALUATION
� � �.. � State FOrtn d3709 (R71 / 6-09)
�` Presai6etl M�PartmeN of Lasl Government Fitunce .
�,rRUCnoNS:
F
To be �led in person w by mail with the CountyAuditor or Counry Rewrtler of the counry where the property is located. � ' �%
Filirg Dates: f) Real PmpeRy: Must file dunng the year fw which (he deduction is mughL � Coun ry R'uditor
2) Mobde /Manufactured Homes rwt assessed as Real Property Must h7e dunng fhe fweNe (72) months C.��--�— �er
befpre March 37 of each year Ne deduction is sough[.
See reverse side loradtlrfional inslructions arM qualifications. GIB
MP�N (ownar mwntrad buyer - see restrirtions m reve ^si0e) . /J � �f .�. '_ R
_ nn �
q.�e� ralue d real P��9 as a
MalCh 1. ame� Year
If no, wha�'s h's / Irer e�ct sheR of in
If twne an fecvd is 6lleraf� Nan that
r+ame ot mmeasee «mriva�t s� �_
`GC
eress of rtartgagee «mno-aa seu�
, �
�l 1-lY - / Od -c�e
NpRqa9e / Contraa indebtedness �
NarCh 7, airtenl yeer
uiAkdie bebw.
c. S.
d stree; cdy, s+ate. arrd LP code)
� oNer owner w holder of mM9a9e
�(num6eiandsne ty•smte.anC$/PmCe)
properly in any other- � Y�. �
nvx ❑No
Oeduction aVWovad'ui ihe amount ot
20_ p �\� �I`�
Sig�tlnedCa�mNA�Witor V \\ �
C • T. )ti`'m�'� ��\
I I We certify ufder the penalry of pe ry thai� �
nwnrr�/ mntrad huver of the afaementioned p.� ��PP
Fwi ent atldrea of app5rant (number antl sbee4 mJ: �te. anC LP mtle)
�� 5 Z3� l,� •�i ri x c�
Person aufharzeA by duty ezeartetl Po+�e� of AttomeY ��' IC 61.1-12-0.7
Mdress of authw'vEd person (number antl sbeet. cNy. sbte. ard ZIP catlo) .
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RemN raunbrl va9e numou
-O� %d �Y
as d Mortga9e / Contraa uMe6ceMess unPaid as d Is ihe aPP�^t ihe sde
tlate of appfmatian � a ��e �
� � ❑ Yes ❑ No
! owned wiN someofre oNer Ihan se. indicete with whnm
I5 Ihe WoGertY in puesOm: Mnua�Y As5e5sM
CC�� �ce�v ❑ rw?!,�nv � . . .
Wh2tTad�g
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Draiver NO.:oZ0/�'......!.
Card 1�'O. ....�/" ,
# �5� G100, cp:' .. ..
No
20 _ 20 _ 20 _
/w��y -- . � I Date (monfh. daY. Y��)
/I
umalion is We and cortect anA t�at Ne applipn[ is a resident of.l�iana and
is filed.
� Date (morvh, day, yea�
�� �„KK�.