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"'+ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C ow ear
:, _--..
� FOR DEDUCTION FROM ASSESSED VALUATION
� State Form 63709 (R11 / 6-09)
' y� � Presaibed M �eP��N a( Laml GovemrtreN Firence
File Mark
INSTRUCTIONS:
Fwm ed wkh:
To 6e �led in person or by mail with the CountyAuditw or Counry Reco/de� o/ the oounry where the property is located.
Fif'mg Dates: 7 J Real Pmperty: Must �Je during the year for which the deduction is sough[ � �o �y q�d��
2) Mobile / Manufactu2d Nomes not assessed as Real Pmperty Must file dunng the twelve (72J months ,GS
before March 37 oleach year the deducfion is sought °� ReCOb�
See reverse side 70� additional insWCtions end qualilcations. G IBSO
�
If f10, W�ldt 6 �IR /�12f 2Ydf15�1319 01 VI}BfCS��
.r I legal desaiptim
-r7 -a 9-aoo-ooy.Sr�.va
MoRgage! Cantraa irdebteEnesS unpaitl az af MoRg3ge / Cont2tt ind
Mard� t. a�rent year date of eppGmtim
on remtl s CiRerent Nan that of aDp6ran�
Name of rtnrt�ce or contract
nnryagee w mnttaU srLer (numM� and stree; ciry, state. aM LP code)
Name a� ass'upi�ee or oNg awner w halder N mortgage
Add�ess ot assignce (number aM stree; dry, stete, antl
Does epplimnt rnm property in eny oNer
munry in IMiana? ❑ Yes
❑ No
Deduction approved In tlre amount of.
20 20
W�.
�
Wtut T
COUNTY AUD�
2�
Rewrd number Page numDer
�-009 2., ,j �
impaid as d Ls Ihe applkant Na sole
legal ro epuitade v.mef.+
❑ Yes ❑ No
dkate with whom
perty in Quesfion: MnuaOy Pssessed
PmaeKV ❑ Mn!�aMAsse�ed . . _.
�-
Dra�rer 1\'O o2(� --- --
Card �\'O. .. � CJ,3(o .... .. � No
`� 3�, 32� ��...... ... -
20 _ I 20
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I/ We certify�inder Ne penalty of �rjury that Ne above arW (oregoing informaGOn is We and cortecl arW that fhe appiicant is a resident o( IrMiana and
owner / contrad buyer ot Ne afwementioned property on date application is filed.
iniWre (owners 6�me) � ' _ Date (mmih, daY• Y��
�� �
Full witl addmss d appGmn
Person aWqtaed Cy dWy exea
Pdtl2ss of aWro�'vetl per'.,on (i
dry, s1a1e. � ZIP cotle)
or by IC 61.74
sbeet �ry: state, an0 LP code)
Date (rn0+�fi. daY