Mortgage_Matney^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7rn
_ FOR DEDUCTION FROM ASSESSED VALUATION
• Slate Fwm 43709 (R11 / 6-09)
S I p�y�� p�, pePaNny�q of Laol Govemmerq Firance
�STRUCTIONS:
Form Ni
ro be filed in person a by mail with the CounryAUditor or Counry Recorder o( the county where the property is located.
Filirg Dates: 7) Real Pmperty: Must Tle dunmJ fhe yea� for which the deduction is sought. (� V 2 Z�
2J Mo6de / Manufactured Homes rrot assessed az Real Properly.� Must file dunng the fwelve (12) mo�A§
before Marth 31 of each year the deduction is sought.
C�.
See reverse side 7or adddlonal instructions and qual�cations.
owrier or conlraG buyer- sea resfnUions m�ve side)
/ BSON COUNTY Al
T' Disbut KeY nimber / leyal EesaiP�^ Reco�d rwmber
(o - -o� - 00 - Do 5� - o a
n�ssm � r� aoa�r �ape i co�o-aa �c�a� ❑�pam � w nwnqaye i cd,o-�a maeccea�� �,�,cam � of i
s Ma�di t. year 1. airtem year Eate ot aOpGption i
It ro. what a his / her exac[ share ot mterest? ' I 1( o�me0 wii� someone oV�er tl�an spouse,
name on reoord is diReren[ Nan Nat ol apPlicant hMiCate bebw:
�� a �� ��e�
aearess m nnrt9a9ce «m,o-aa st
Nama of assiip�ee w othu awner w
�i asvgnee (num r antl street u+Y. s+Ne. am t�r 000e�
(� - 3 - /
lita�rt ovm property in anY oUer If yes. what munry?
Ind"vna? ❑ Yes
❑ No
DeAUCUm aPWm'� in Me
20 _ � 20 _
�natureW unryAWitw
I/ We certify under the penalry ot
owpery contract buyer of ihe aton
20 � 20
Vlha
Ca�n
Ne above a foregoing infortnatia
property o ate appl"ration is filed.
�uil�tlent atldress of appfKant (numDer antl s7ree( tlfy state, and ZIP ca
d�' G 31 ? l.v S�7S5 '�
Person auttro(aetl by dWy ezecutetl Power of Attdney or by IC 61.1-12-0.7
Pdtlress af aulhor¢etl persm (number aM sbeet. fity, Yafe, and ZIP ao0e)
/�'�� T,�E y�
l��Cl�l�,�D 71l
�A�y s
��, ��� /
Year
Co�nry Audiinr
County Recorder
Page numEer
vi �
Yes LJ No
f
�
No
antl