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^•� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Year
__ _ FOR DEDUCTION FROM ASSESSED VALUATION
:. �' State Fortn 43709 (Rt t/ 6-09)
�' ,,,, � PresaibeE by Depanmerit al Local GovemmeN Fuance
Fil�b1
INSTRUCTIONS: f"
To be lded in person of by mail with Ihe CountyAUditor or County Recorder o/ the counry whe2 fhe property is located. F� fl� �:
Fdiny Dates: 7) Real Property: Must file dunng the year /or which the deductbn is so�ght. 6�•��{j���
2) Mo6Re / Manulactured Homes not assessed as Real Pruperty: Must file during the fwelve (12J months
before March 37 oI each year the deduclion is sought ��^ e�
G S CO
See reverse side fo� atltlitional instrucGOns arM qualilcations.
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;i 1q. �Ma151115/ tre� eaaU sl�are 0� IntereSC!
tt rwrie on recwG's tltlferent Ihan Ihat af app�nt, 6WVate below.
Name of mutgagce or conttar� seller
nearess or �nrtgayee «mnrraa seu
„s:r
��.
Name M as4gnee a W�er owrer or nolaer ot morigage
A4C25s of assiqnee (numDer antl stree4 a1y. s(afe, and ZIP code)
Does applitant wm yopeny in any oNer If yes, what
mumy in Ind'ena?
❑ Yes ❑ No
o. is��-oaa
az ot Mortgage / Contra�Y irWe
date of appti�ation � I w eQWtade wrtre(�
�� �`J � � ❑ Yes ❑ No
Itovmed with someone othfltthan spo�se. iMicate Wih wMm
Is PbPeM om O�usCO2 /wwaM Assesud
Real Roperiy ❑ Mnually Assessed
COUNTYAUDROR
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20 20 20 20 _ 20 _ 20 20 _
��anne U Cour.b AW itw Counry Date (mmth. daY• Y'�+)
I I We cerdfy uMer the penalry of perjury thai the ahove and foregoing infortnation is W e and mrtecl and fhat ihe applicant is a resident of Indiana and
owner / contrad buyer ot the afo2mentioned pmperty un date application is filed.
r¢ (� �m¢� � /� 6ate (nmfi_ daY. Yga+)
`rW)�entad�es.��a nf(num6era ary, ate,antlLPoode)
°9� j �; �� �.32n. C�
Person autMrized Gy duly execute0 Power af Atfamey or by IC G7.1-12-0.7
PdEress of authomEO person (numbu arM svee; ciry. sfafe, aM LP code)