Mortgage_Presnell�
""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
__• FOR DEDUCTION PROM ASSESSED VALUATION
State Fofm 43709 (R11 / 6-09)
�' ,�„ j Presrri6eA by Departrnenl of L.oral Govemment Firerze
le
wsrRUCnoNS:
Fmn t�ed wi�h:
To 6e filed in person w by mail with the CountyAuditw or Counry Recnrder of fhe counry whe2 Ihe property is located. g ZO��
Fif'mg Dates: 1 J Real Pmperty: Must file dunrg the year Por which the detluction is sought. ��unry Auditor
2) Mo6ile /Manufaclu2d Homes rat assessed as Real Property Mus! file dunng the tweNe (72) months
before March 31 of each year the deduction rs soughL �. �e�
See reverse side (or additiWnal instrucUOns and qualifirations. �OITOR
.__�__.,_..---__��..--- ----'_-"------_ _ �_. _,,., arrtl8'fY —�
�
Ps�ssed rah�e d real pcperty at ot
Ma�U 1. aarent year
aU
Key numbu / legal desaiption
- 9-/a�-c�i
Mortgage / ContraC iMebtedness
Mamh 1. Wrtentyeer
what's his l her erxt share of interestt
If n3me On 2mttl a
rtwrt�jagee or contrarl selier
below
contratl se0er (nurMe� and streef, cif};
rvame m assgnee w omrl wmer or naaer o� npnqage
(nurtr6er aM stree4 �Y, sbte, and Z/P catle)
Does appli�ant am property in any oNer
counry m Ind'ana?
❑ Yes ❑ No
��7-� �
DeducCOn apprwed'c� tlm amount of.
�_ �_
yes. whal
20
�
ra-�
as of Mor�qage / ContraU
date of applintion
^�•^^er Page numCu
�/ �
as of is Ne applirent Ihe sale
legal a equilade ownM
❑ Yes ❑ No
If oxned wiN someone aNer Man spouse. i�ifate with wlwm
auo
Is the property in puestion: MnuaDY Asessed
�j2eal PropeAy ❑ Mnually Pssessed
Dra���er NO....°?0/O
......
7�Y
�I
Card NO. ...,... a��.......
�'7$,7C0. "—' —
20_ � 20_
Dete (rtnNA. daY• Y��
20 _
i/ We certify under Ne penalry M perjury that the above arM foregoing infwmation is true and cortecl and fhat Me applipnt is a resident of Indiana arM
awner % contrad 6uyer of the aforememioned pro0erty on date application is filed.
execvted Power of AupneY or Oy IC E1.1-12-0.7
Mtlress af aWio�rseA D� (numberaM svect �N• sta(e.
Date (rtrmfh.