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"�n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun ovmship Year
�_,_ FOR DEDUCTION FROM ASSESSED VALUATION pE� 2 S 2 �9
• State Fwm a3709 (Rt 7/ 6-09)
�' ,«. f Presaibed M DeP��rtl of Lnml Govemment Frence
F�le/� ark �%i,�
INSTRUCTIONS:
To 6e filed in F� q� �
person w Dy mail wiN the CountyAuditor or Counry RecoNer o7 Ne counry where the properry is located. �OUNTY AUDITOR
FiNrg Dates: 1) Real PropeRy: Must file during the year for which Ne deduction is sought. C' S Counry Auditur
2) Mo6ife / ManWactured Hortres not assessed as Real Property Mus! file dunng the tweNe (12) monNs
before Ma2h 37 of each year the deducfion is sought. ❑ Counry Recorder
See reverse side 7or adCitional instructions and qualrfications.
AppGwntiowner�orp�ntrdGbu r e�i�-�.rc�/n�e' [ .�r� ()
YY 1 h 7
� � P�D�Y �
Y�
m
M mortgagea or contract seller
Pddtess of mortgagee w mntraa se0er
Name of assignee w
- - -iti � -WC�. i v -
Mortpage / Contraa iMebtedness unpaid as of Mortgage I�
Marrh artent yeer tlam o( app
ao
�r o�.,»a �;m �r�r
owi»
cant,'u�Gicate bebw.
( `
ier arM street, ', sta.e, aM ZIP code)
nprigage
�dy, s�te, entl ZIP cade)
Gfsn[ ovm property in any other I If yes, what muntyt
trdmia?
❑ Yes ❑ No
De�ucGOn app�oveE in ihe amoun
zo _ zo
Signa4rte of CounyAUCitor '
AUDROR
Remrtl numbrl PaBe num0u
tetlness unpaid� d Is Ne appOrant ihe sde
tegal w eWttable owneYt
❑ Yes ❑ No
spouse. 4dkate with whom
kIs�,Ih—e property in pues0on: MnuaP/ AssesxW
�eal Pmperty Q MnuallyPSSessed
� n.a,w�w w�w nr ��_t-;
Dra�vcr \io..a�9........�
C:11'(i ���. ... �. /.J.Y.......... No
.� q�,���•U'� -
p— � �— � p—
Counry
zo _ � zo
oa�e tmwn, ear. r��l
I/ We cerory under Ne penalty of perjury that the above and foregoing infwmaUon is We and cortect afM that the applinnt is a resident of Indiana arM
wmer I contract buyer of Ne atoremerrtioned property on date applicalion is filed.
rtiaw tnwtrers mm �ame) n oate (irwnm. dar. yea�
FWI
IC Fr1.142-0]
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person (number antl strcet, ciry, state, and LP oode) . �