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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS n sh' Year
:r:—..
FOR DEDUCTION FROM ASSESSED VALUATION
• Sta[e Fortn d3709 (R77 / bO9)
S Pmsaibetl Cy �epartmern of Laal Govemment Firence «
�w File Mark
STRUCTIONS C � om�
To 6e filed in person or by mail wiN tlre CounryAuditor or Counry Recorder of the county whe�e the pioperty is located. F�� p���
F�7ing Dates: i) Real Property: Must file durirg the year for which the deduction is sought. n� q�d�
2) Mobde /Manufactured Homes not assessed as Real Property: Mus! file dunng the hveNe (AJ86R1�sCOU �TY�1D �
before Ma2h 37 0/ eacA year the deduction is sought U Counb Recorder
See reverse side for addifmnal inslructions arW aualifications.
Appfram (owne� m convart buyer- see 2sfictions m rse sitle)
C
Ta ' Ois ' Key rn�m0er! legal desaiption Remrtl numbu Page num0u
a - o - 3 - - -6 0
Ps� va4c d real pfopeny as W Abr�qage 1 Contraa'vdebtetlr�s unpaiE as of Mongage / Contrart'uMeMedness impaitl as d s Ihe appuant ihe sde
Ma�d� 1, anen[ year Mamh 1, n�rtent year datc af appGcation legal or equRable wmeY?
❑ Yes ❑ No
If no. what fs tris / her euU share o( interesi? If owned wiM sameone dhar ihan spouse, indipte with whom
It name on recad s GRUent Nan Nat ol aCP�m• uW'xate beb�r. Is ihe P�GertY in Cue50on: MnuaM Assessed
eal Roperty ❑ tvmua�y A�ssed
Moble Fiorne QC 61.7-7)
Name of mortgagee or conuarl seller S
AAtlress ot rtartgagee or mntract seller (number aM 4��: sbte, aM ZIP code)
Name ol assignee w other owner w hai7er of mortgage
Add�ass of assgnee (number aM sdee; trty. slate, and ZIP code)
Does applifant v+m property in any Wtip If yes. what munty? What Tanrg Disf`iU? Has Na deduGim been repueste0 m pmpnty
munryinlntliana? ❑ No fwartentyeaY.+ � Yes ❑ No
❑ Yes
� COUNTYAU�ROR
Deductian approved'm ihe amount of:
20 20 _ 20 20 20 _ 2(1 20
Sigfature d Cau:ry AuGttar Couny Da�e (mwvh. CaY• Y��
I/ We certify under the penalry of perjury that the above anE foregoing infortnation is We and corteU and that Ne appli�ant is a resideM of Indiana and
owner / contract buyer of the aforementioned property on date application is filed.
Signature (o�mers !W nartre) Dare (rronM, day, yea�
FWI resident atldress appfiont (wmDar and shee4 . s+are. antl ZIP aotle)
� S � = G�
Person autlro�¢ed Dy dWy ezenitetl Power d AtmmeY a bY IC 61.1-12-0.7 Date (rtmN. Aay, yean
MCress of authwrzed person (numeer aM snee4 �: slate, antl LP mde)