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'°'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
:. -..
: FOR DEDUCTION FROM ASSESSED VALUATION
� Stale Fortn 43709 (R11 / 6-09)
S w. ? Prewibed by DePaM�M o( Local GovemrneN Frence
�srRUCnoNS: � eaw,9t�f
be filed in person w by mail with the CountyAuditor or Counry Recortler o/ fhe counry where tAe property is bcated. � 4 C u � 1
Filing Dafes: 7/ Real Property: Must file dunrn� the year lor which !he tleduction is sough[.
2) Mobi/e / Manufactured Homes irot assessed as Real Property Must h7e dunrn� the tweNe (12) months
6etae March 31 0( each year the deduction is wught.
See reverse side fmadd'NOnal insUUCtrons and qualifications. GIE
AppGran n r`arc�ont�a�ab�uyar-seerestrirlionson�¢vers¢side)
w C�L�
Ta�drg Distrit Key rumber / legal desaiption
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Assessed aF real as W ' �br(qage / Contrati indebtedness unGaid as W Mortgage / Concrae'viEebtedness
Matd� 1. anenl year Mgich 1, wrmst year, date ot appfimtion
�t rw.
If name m �emd is SA!erent Uan
Name of nwrt�jagee or contract seller
Pddres of nqrtgagee w cmtracl
owner or haltler of mortgage
ier aM stree4 �y. sfafe, and
Dces apptkanl ovm property in any oNer
counry in IMiana?
❑ Yes ❑ No
Deduclion apywed'o� Ure amoum at
20 _
Sigrianue o( Camry Autli
L " 1 "
1 I We certify urWer
�er I contract bu
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as d Is Ihe aPP��t Me wk
Iegal w equitahle oxnM
❑ Yes ❑ No
If owned wiih someorre other than spouse. ifWMate with vA�wn
eet, cRy. sbte. arN ZIP codej
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GOUNTYAUDROR
20 _ � 20
by Cuy exewtetl
ry of perffry that the
aforementioned pro
20 _ � 20
Counry
l51M P�Pert1' in 9ue50m: MnuaOy Assrssed
L'�R� �v�v O ��r�
Dra�ver NO...`?.� �I.'......
Card NO. ����
i 55, �v. �
�
Date (monfh. day. Yea�
2(1 _
� and foregoing infortnaGon is We and correct and that Ne applicant is a resiEent of Iridiana arW
on date applicatlon is filed.
Date (mmCi� daY• Yea�)
state. antl LP oode)
�c�;Li.e s� u7,
Pddrrss o( autMrrzed pe�von (numGer arM sLae( tlty, sfafe, antl LP cotle)