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"n STATEMENT OF MORTGAGE OR CON7RACT INDEBTEDNESS Coun Township Year
_ ; FOR DEDUCTION FROM ASSESSED VALUATION
� Sbta Fwm 43709 (R71 / 6-09)
, � Presmbed by DepaM�eM af Lo�l GovemmeM Flrence
File Mark
INSTRUCTIONS:
To be filed in person w by mail with the CountyAuditor or Counry Recorder of the wunty where the properry is 1«:ated.
Filing Dates: 1 j Real Pmperty: Must file durirg the year (or which the deduction is sought.
2) Mobde / Manu/actured Homes rat assessed as Real Pruperty Must file dunrrg the tweNe (12) monfhs
6efore March 31 of exh year Ne deduction is sought.
See reverse side 7o�ional instructions and qualilrcations. G�g�
j MO�nt (owner or ' tre jexer- �ee rc ' rere n � . ^ � / _ . .. �.
Auditw
Recorder
Key rwmEe�iegal d P�^ � O—� I_ l�l C/l� /'• J�J ���� / P�e�O` ./ V
b
7��Y A1ortqa Be / ConhaC intle6tedncs unPaid az of MoRgage / Canaact'viEeMeEness unGaid az of Is Ihe aPP�xsnt the sde
Mamh 1, date of appGtafim kgal w equitab�e awnelt
� oo� ❑Yes ❑No
exact share of interest? If wmed wiN sameone other �han spouse, iMuate with wiwm
If name m remrd is tlifferent Nan Nat of aPp6rant ��� bebvr
Name ot mortgagee a mntraa seYu
Address ot rtmrtgagee w contrad SeYer
w other ovmer w MIEer ot mortgage
LP_ rn+a)
Dces aPN'v�•' �' ^ 3t
aoQ�}
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D1•a��'ei- \0.......
� 3a30......
- Card ��• ............ �'J
� �a�,�- -,
I/ we cert'rfy unfier the q
owner / contraG buyer of
of perjury that the �
orementioned pro rt}
r{��`street �l: sb/re�.
'O V .) r l 1
owe+o( Attomey or by IC 1
AEdress of authorQed persan (numEer a�M street, cvry, sfate,
Is ihe property in Question: MnuaDy AvesuW
� Real PtoPenY ❑ ����Y �
Modle Flort�e (IC G7.
Has Nis dedudion Deen re0uesteE an proprlty
(m a�rent yeaR ❑ I
� Yes
COUNTY AUDITOR
20 _ 20 _ 20
Counry, _ _ D
zo
e and foregoing infortnalion is We and mrtect and that the applirant is a resident of Indiana arM
on date application is filed.
Date (rtrmih. daY• Y'sa�
2-0.7
Date (monlh. tlaY• Y��