Mortgage_Straw'°n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship Year
__ FOR DEDUCTION FROM ASSESSED VALUATION
• Sfata Fwm G3709 (Rit / 8-09)
��.�. Presvibed by DepartrtieN o(LoW GovammeM Fuance '
File Mark
INSTRUCTIONS: F� m� ��:
fi be filed in person a by mail with the Counry Auditor or Counry Recorder of the county where the property is located.
Fil'mg Dafes: 1J Real PropeRy: Must file durirg the yearlor whicA the deduction is soughL � Counry Auditor
2) Mo6de / ManWactured Homes rqt aaessed as Real PropeRy: Must f+le dunrg the hvefve (7Y) months
6efae Marcfr 31 oi each year Ne deduction is sougM. ❑ County Recorder
See reverse side lol addifiQr(8t instnrctions and qualrfications.
MP���(owna�ormitra� �9^��E��e) �_ 1 �
Key
i1. anent year
I7 m. what ts his / hu e�od share o(
Mart3� 1 e
-� a- �o�-
tle6tetlness unpaid az of
unPaiE as ot Ls Ne aPP��t Ue sde
kgal or eQUitaWe a�ne(i
❑ Yes ❑ No
someane dhet Nan spouse. Ndicate wiM wtnm
tt name m reoold 6 dtlfPJenl Nan Iha� ol aCP��L Ind'uate below.
Name of mxt�a9ee or mnaaU seper � r-�
\�
Pddtess of momJa9ex ar mntraG sr�u (numDrl end sveet �N• te. ard LP mde)
Name of assignee w oihu ownet or hdder of mat9P"°. _ _ . — _ _' _' ' . _ _ .—,� -
nearess e� assgnee (� �e streec �r. s��. ,
Dces apptksM own P�O�Y
mnuy in Naana? r
2�
Signahrte
af
Dra�r�cr NO.....°.2.�� �
Card NO. .... �.��2.......
� 31, 500,�0
�— i �— i za i �
Counry
Is the poperty in puesUOn: Mnua�y Assessed
� Real P(oPertY ❑ ��Y �
Has Nis tleEUCtbn Deen reduestea m propelty
tor arrent yeaR ❑ Yes
❑ No
� �
Date (monM, daY Y��)
I I We ceNfy under the penalry of perjury Nat the above arW foregoing infwmation is We and wrtect and that the applirant is a resident ot Indiara and
rnmer I contract buyer of Ne aforementioned property on date application is filed.
7�aWre V eh fiNnema) _ �_�c_ �(�. daY.Y��)
Pelson au0ro�ized by duh/ exewteC Powe� of Fttomey w by IG 61.1-12�.]
Address of auttnr'¢ed persm (numbareM sbeeL �dY, sbfe. anE LP code)
� � �7�' �� � �
Date (monfh. OaY Y�A