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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou ni vear
__ ,� FOR DEDUCTION FROM ASSESSED VALUATION
• Stata Fwm 43709 (R71 I6-09)
�` PreSRiEeC by Dep3rlmeM o( LoCal Govemmerrt Frtlance
� Fi a�Q��
�STRUCTIONS: .
To be �led in person or by mail wiN the CountyAuditw or County RecoNer of fhe county where the property is focated.� C �
Filirg Dates: i) Real Pmperty: Must file dunng fhe year Por which Ihe deduc6on is soughL � AuditOr
2) Mo6i(e /Manufactu�ed Homes not assessed as Real Property: Must file dun�g the fwelve (12) mor��SON CO�TYGq�Jl9��rder
before March 37 0/ each year fhe deduction is sought.
See reverse side for addifionel inshucGOns and qualificafions.
�yL71 �l.b '
rty as of
share o( interest?
desaipUOn Remrd number
- Ig-�e� � c�c�.� �-oa � aa� a
ae / Contraa'vdehtediress unvaid a ot Mongage / Canaaa vi0e6teAr�ss unvaid as d L
7, airtent y�v tlate a/ eppG�tion N
If name m �ecord's 6f,erent Nan Nat o( appGranl i�Mirate bebw.
m mormau� a mnvaa sN�er
rc ownea wim somea» otl�r ma, spasse.
No
perty in qunstion: MnuaOY Assessetl
�nv ��M�
n�oa� � nc e
of rtprtgagce<r cantracl sWer (number arid sfree; ciry, state. aM ZIP code) __'� ... .
�_ _
assignee or oNU awner w holEer of mortgage ' ^� 1�
/ �
of assgnce (number a�M slree4 �X sfate. aM Z/P code) D 1�:� \�' O l� � O . . oc . . . . . . . . . . . . ..
Oces applinnt wm pmperty in any oNer
m,rur��mee�a� ❑ ves
20
Sgrenne
20
iry�.wnacw�ory.� . C�3 Y �
Carcl NO . .....................
� /J7,�roo. �
COUNTYAUDROR
20 � 20 _
Caunry
20 � 20
��
m pioperty
20 _
I/ We certify urWer fhe penatly of pe�ury that Ne above aM (oregoing infomiaUon is We antl corteq aM that fhe applicant is a resident of IMiana and
owner I wntract buyer of the afaementloned property on date applicatlon is filed.
���N,w�.wercf�Ui Date (rtmtl�, daY.Y�A
aty, state, a+d
� Nol t. C�cusf S-}, f"vr-1 tSraJ,
Person auNorizeE Oy duly esewted Povms al Attomey m by I
Atltlress of auMOrrsiW perso� (num0er arM sveet. ciry, sla(e,
oa� p,b,�m. day reeo