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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
_ s FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn G3709 (Rt1 / 6-09)
,' Pr�wibed 6y Departmer�t ai Lami Govemment F�anca
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INSTRUCT10N5: F�n�do�yn
To be filed in person a 6y mail wiN the CountyAUditw or Counry RewNer o� the county wfiem the property is located. U C t, �.7 � U
Fil'mg Dates: i) Real Property: Must file during the year fo� whirh Ihe deduction is soughG � Counry Auditor
2) Mobile /Manulactured Homes /wt assessed as Real Pioperty Must file dunng tha tweNe (12J months
6efore March 31 0l each year Ne deductiWn is sought. �; ��ry�O�.�„�?7�.���
See reverse side foraddifbnal inshucGOns and qualfications. n� ���,�y '��B�fiBR
IMW�^t racgn7rad6uyer-seeres7+�tonsmreversesiCa) n v�.
� Mor(pa - `�lo�-00% Qo- oa�
Assessed rahm dreal popatY as of ' Marti� 8, anenl 4debtedn� unPaid as of aMo�9a9�� mdeM
i ,.�� ia
n ro. what Ls nis � nvl evd Share a mteresta �r awnee r;m somea,e aher wn s�
If narne m remC b AiRerent Van Nal at aPP�t mdi�te cebM' k
Nart1e ot rtqrtgagee Or tontracl u4er
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Address d rtwtgagee w mntract seAer (n r and s0
Name at assiryiee w ot�er owner rn hdder of morigage
AdCBSS of assi�rm (manDer aru! sexet �Y• state. and
Does eppi�ant own popaty in any other
munry in Indiana7 �._ �..
ciry, stete. end LP cade)
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numbrl Page number
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3s of Is ttre eppt'imnt Ne sde
Y� u No
e P�GertY in Questim: M^ua�Y PSSe55e0
Real RoPenY � A^^��Y �
Mobile Harne (IC 6
Nas Nis detluCim Deen reGUested m qoperry
far cunmt Ye� � Yes ❑ I
A� � , ) COUNTYAUDROR
eu�more�- � �n��pL� l.l./
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-� N uso�, ��� zo 20_ �_ zo_
��ah ���D Counry Date (monlh. eaY• Y��
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�� W� J(/I ..� egoing infortnation is true and cortect arW that the applirant is a resident of Indiana arW
awne. G� �...yerty on date aPW��n is filed.
aO�Ye .. Date (morah. daY. Y'��
(lq5o S�a���.e t ti`�,8 t�Z�'�an�-�. �N W7(��
Person aWpRetl Ey CWy ezecuted Pawe+a(Aitomey or Cy IC 61. t-12-0.7
Atltlress of aWmrtred person (number and sbee; riry, state. eM ZIP cade) .
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