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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou sh' r
J__ FOR DEDUCTION FROM ASSESSED VALUATION
• Stata Fortn d3709 (R11 / bO9)
,' w. Presm�bed M DeOaRmeM of Loml GovemrtreM Fuanca
File Mark
wsrRUCnoNS:
F
To be filed in person or by mail wiN the CountyAudRor or Counry Recorder o/ Ne county where the property is bcated.
Filing Dates: 1 J Real Property: Must file durirg the ysar for whicfi Ne deduclion is saughL Counry Auditw
2) Mo6de / Manufxtu2d Homes rat assessed as Real Property. Mus! file during fhe hvelve (12J months �� .��e��
6e(ore March 31 of each year Me deducfion is saght �
See reverse side !or addrfional inshuUions end qualrfications. G�B -�� �----
ADP��Mi�rarmntradbuyer/seer�ttricb'o};enreverseside) � n � /I
AsesseE vapie af � P�oPerry as d
A18tdi 1. o+mY yea
If no, what is his I her eta�Y share of u
11 �ame m remtl is difterent Nan Iha
rlame m rt�ga9ea «ca,aart sel�a
AdAreu of rtnrtgagee a mntracc seA
Name at assynre w ather wmer or f
PDtlressolassgnee(numberandstr�
� n —c..co � �,� v �
�C9a9e / Contra¢'udrbte
MarM 1. wrtenf yeer
�nt,'uMirale Gelrnr.
0
rer ard saeeG cdy, smm. ane LI
mortgage
�br.. antl LP mde)
limnt oMn property in any oNer
In0"mu? ❑ Yes ❑ I
o�a�aon aoo�a m,n� a�,�,H
�_
Sgnanne U Co�aib nudrtor
�
H awned wit� someofre oNer ihan
T— � � ,u —
5 �,-r �p � � l3;°`'°� -
AGe �-
� Jpa�Kd�.� moR�/�/IC� ;
i
aa�D - ��oo
Caunry
�mGaN as of Is Ihe aPP�� Na sde
y� legal «equitade o�nll
y , ❑ Yes ❑ No
ie property in QuesGm: MnuaOy AssesseE
Real aroaeRV ❑ �^^!�M �
N"s Cetludion Oeen rcQUeste
u�rent YnaY? ❑ Ys
�
Date (rrmfh. daY. Y��
P�Y
❑ No
20 _
t/ We certify ufWer the penalry W perjury that the above and foregoing intomiation is we aM correa arM that the applirant is a resident ot Intliana aM
owner f contract buyer of the aforementioned property on date appiiration is filed.
�`i,_/Y� G �Oi • (�(/ / � Date (momA, daY. Yga�) _
Petwn
im6er aM sfrec4 bN, �te. arM ZIP mtle)
� I 5`r. -� �
pyx¢rW p,ppmey or q IC 61.142-0.7
of auCia'aed person (number arM sbee; dry, state.
1 C�� _ � JJ �i 7 �