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""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tavnship vear
FOR DEDUCTION FROM ASSESSED VALUATION
Sala Fwm 43709 (R70 /17-05)
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INSTRUC710NS: i y
To 6e filea in persm or by med witli Me CdrntyAud"dor d fhe covnty where fhe pvoperty is bceted.
Fu�y oates: �� Rea� P,opeAy: Musr file d�ir,9 ma yaa, ro� afiicr, fha aeaudro� rs sd,ync J U N 2�� Z 009
2J Mo6de /Manulactured Homes nU assesse0 as Real Property: Must file dunry fhe fweNe (!2) monfhs befwa Ma�ch 31 0l each yee�
the detluction is spgAL
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ssesseEValued`ealpraperyaad A/art e/Canirad'u
�rn �. �m raa �. m.am r��
m, what is his / her e�d share d i��eSR
name m recnd is d�eraM Uan Ihat W appfrsr�, rtqiab bebw.
Pddress of morl8agea «
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Deeuaion aaC�oved in me amann d
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dasd MaNgage/<
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indebteEness w�aid as d Is the appqsM Ihe sde
�egal «eauiUnla wrrert
3�� ❑Yes ❑No
�a G�GaM in questim: AmwM Assessed
Real Praperty Q MnuaOy AssesSed
Mohile Fiare (IC 6
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20 _Q,�_ � 20 � 20 _ � 20 � 20 _
CoumyA�ditor
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20 _ � 20
Data (maMh. daY• Y��
I/ We certify under fhe penalty of perjury that the abwe and foregang infom�ation is We and cwred and that the applicant is a resident of Indiana antl
owner / contrad buyer_of fhe aforementaned property on date application is filed.
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MErass d aulhorizaE parson (number arW sbeW, �Yy, ffifc. and LP rode)
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