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"`+ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
�_,. � FOR DEDUCTION FROM ASSESSED VALUATION
� State Fwm d3709 (R71 /6-09)
� y�. Prestribed by DepaNnaM of L.aml Gavemmenl Frence
INSTRUCTIONS: n p,ortnMe1
To be filed in person w by mail wiN the CountyAudROr or Counry Recader o/ Ne county where the pioperry is Ioc�f�C 2 V� u 1 U��
Fi/itg Dates: 1) Real Property: Must file during Ne }rear (or which Ihe deduclion is soughf. � County Auditor
2) Mo6ile / Manufectured Homes not assessed as Real Property: Must file dunng the fweHe (72) rtanths
be(ae Maich 37 o/each year the deduction is sought. �"Jls,M Counry Remrder
Sea revarse side tor additiona! inshuctions and qualificafions. G �BS � v
I AG,M�QI (owner or convarl buyer - sgp resvirtiorts m reverse side) n � A �
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It rw. what Ls his 7 her erarl �ara ol interest?
If riarne on �emrd is 6Rem�� Nan tlut of app6rant, 6Wifate below.
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Name W nartgagee a contraG
Atldres of mortgagce w mritre
Name at asvy�ee w othu owner rn naaer ot mortgage
ACdrPSS of assg�e (n u aM stree4 �N: slafi, ar�
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Dces a�kam o.m pmperty in any oNer
�a,nry in maanaa
❑ Yes ❑ No
F39
IIWec
owner I
��.
az
ReWrtlnumMl Pagen�m�ei
d�0i0 SS `f�
unpaid as d Is Ne ePWimni the sde
legal or eQuita6k oMnel/
❑ Yes ❑ No
If avmed with someotre aher Ihan spouse. Gd'xate wtth whan
Is tl�e propertY m Questian: MnuaAy Assessetl
❑ Re21 PmpertY ❑ ���Y �
Dra�ver NO.. .�n�..Q.�U,,,,,,,
pa� ssy � -
a d a' PT Card NO.
what counp? tMiat Ta�drg • • ••••• • • •• • • • • • • '
0�1 � � ��,a�.ov _
20 _ 20 _ 20 20 20 _ 20 _
fur � CoumY Date (month. CaY. Y��
:
the penalry ot perjury at the above and toregoing infortnation is true and cortec[ and that Me applinnt is a resident of Irafiana aM
yer of ihe afweme � ef� property on date application is filed.
��reh � . \ I o-a� (�m, der, ree�
Fc!(i�nt � �Miy.�t���-CQ�� �cOi � R
Pelson authorized Dy Outy exewted Power MAttnney or Ey IC 61.1-12�.7
Pddress of autlra¢ed person (numbararM sbee; �y, state, and LP catle)
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