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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__. ; FOR DEDUCTION FROM ASSESSED VALUATION
� Sfata Fwm 43709 (R71 / 6-09J
, � Prgaibed by Departmerit of Loml Govemment Firence
�u.
INSTRUCTIONS: eryw�q
To be filed in person w by mail with the CounryAuditor or Counry RecoNer o! fhe county where the property is located. ��� p�D � Q
F�7ing Da[es: 1) Real Pmparty: Must file during the yrear (or which 1he deduction is saughL Counry Auditor
2) Mo6ile /ManWactured Homes rwt assessed as Real Property Mus1 fiie dunng fha fwelve (f2J rtwnths
be(ore March 37 of each year the deducfion is sought. ❑�'.gunry Recorder
4 F3ry�
See reverse side fa additional instrriclions arM quali�cafions.
App5cant,(owrrer v contraC buyer- see m_svi�a m re�rse side) . .. /) /_
DistriG
�
Ls..,,"�
Keynumber/IegalVesmptlm RernNnumber Pagqn� Q /
a�-�7 -09- aoo-oo�. ��7 -o� / o Y: o
qe / Conbaa'udebteEness unpaid as af Mor�gyge / Contract indehteCri¢s �mpaid as d Is Ihe epp6�nt ihe sde
Ma 1, a�rtent yeer date of appfication legal a equitade oxneR
�O 3 Q O � ❑ Yes ❑ No
Irlrst? If awned wi� saneone dher ihan spouse. Wrcate witli wtwm
Name of rtmrtgagea «contrarl seller
�p/tivn'a.'''° °� �'
Addrea of �ratgagee ar conbaG seAer (num6er eM sveaL ��}: sb�. and ZIP coda)
Name W assignee or ofh� ovmer or hdder of mortgage
Add255 of assynee (number aM slree; rdy, stete, antl
���
Yes
DedufArn app�wed In iha amount oF:
20 � 2f1 _ � 20 _
I / We certify uru
owner / contract
COUNTYAUOROR
Is ihe properry in Question: MnueOy Assessed
❑ Real Roperty ❑ ArmuallyAssessed
-�� ___ I
Dra�ti�er i\'O..cx� /
Ca►�d i\`O. ...�?.�.�.��.........
� �03, 000 �
20 _ � 20 _
Caunry
20 _ � 20 _
�Y. Y��
!y of perjury Mat the and foregoing infwmatlon is We and cortec[ arW Nat Me appfxant is a resident of Indiana a(M
aforementio�ed D rtY on date apWipbon is fiied.
dfy, stace. and ZIP code)
Person auNOr¢etl Ey dNy esecuted Poxer W Attort�eY a M IC 61.1-12-0.7
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Date (rtpnN, daY,