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"' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
s FOR DEDUCTION FROM ASSESSED VALUATION
• $Iat9 Fortn 43709 (R71 / 6-09)
�' ,.,� � Presfiibed M DepaM1meM of Lo�l Govemrtierd Fuiance �
INSTRUCTIONS:
To be filed in person w by mail wdh the Couny Auditof or Counry RecoNer o� Ne counry where the property is Ioc��gN
Fifirg Dates: 1) Real Properry: Must file during the }rear /or which the deduction is sought.
2) Mo6�e / ManufaUUred Homes nof assessed as Real Prt�perty: Mus! file durirg the tweHe (72) months
6efore Ma2A 31 0! each year the deducfion is sou�ht
See reverse side Ior addifionaf inshuctions and pualifications. /. �.� / L�� /Q
' i.ammyea �n
tt ro. whal is his / her eraa share o( infemst?
tt rwre m remd is dd[emnt Nan that o( app6mnt
Name ot rtangagee a mntr'aa
� j
I: ���
� CounryAUditor
❑ Counry Remrder
o�
' Rtto�d number Pa9e rwmbu
' U "7 if
intleMeO�ss unPaitl as af Mortgage / Con�aG hMebieCness unDaiO as o( Is Me aPP��t tlx sde
v OateofaOP�� �aeWitatleox+uR
��a ❑ Yes ❑ No
H owned wah mmearre other than spouse. ItMicate wtrh xiwm
is the property in 0ueatio�v MnuaOy Ass¢sed
m�iPmpertY ❑MnuailYPsessed...
Address of mortga9ee a contract se�er (munbrl and streeG �dY. sfele. en0 LP code)
Name at astignee w othei ownu or halder ot morigage
Adtlrasa a/ assignee (number eM sIIee4 �Y. �u, eM Z/P cotle)
Dors a�i�nt ovm p(operty in enY other If yns. what munt/1
countyminO'mna? 1"I .,__ fl .�_
C��o �u���nA,�
�IDI�/ O �
���
Yes ❑ NO
DeEuctlon epyovea tr� vy ap`w�iztg��/� '_... _
v/
2p _ 20 _ 20 20 _ 20 _ 20 _ 20 _
Sig�nne ot Camry NWitar Counry Date (monN. daY Y��
I/ We cerGy urdu ihe penalry of pe�ury Mat the above aM fwegoing infortnalion is we and cortec[ arM Mat Ne applipnt is a resident ot Indiana and
owner ! wntracY buyer ot Na merttbned property on date appl'�cation is filed.
�r�my�� Date (nnvvh. daY. Y�/)
Y�/.�'" // � � / � / 7— ��
F�
Pawn aWrnvetl M�Y ezewted Powe� of
Pdtl�s of eWio�¢ed person (numberaid s
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an021Pcode)
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