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"�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun sh r
__ : FOR DEDUCTION FROM ASSESSED VALUATION
- , Siale Fa�m 43709 (R71 / 6-09)
S ! P�y�p�y py pepy�¢nt ol Lowl Govemment Fnance
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wsrnucnoNS: F� A�a w;n,.
To 6e filed in person or by mail with the CountyAudifo( or Counry RecoNer o/ the oounry wfiere the pioperty is located. C_1 �
Fifirg Dates: iJ Real Pmperty: Must fi/e during Ne year for whith fhe deduclion is soughL � ry ditor
2) Mo6de / Manufactured Homes rrot assessed as Real Pmperty Musf file dunng the hvelve (12) months n C ry�
beforeMaroh3fo/eachyearthedeductionissought GIBS NG`@UNT�aU TOR�
See reverse side for addiLOna/ instructions arM qualifirations.
a�r.- m lr�w.ws m mntraU b - see lesnicn4PYP�� reoerse sifa)
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rc ro, �Mat Ls tus r her e�
It rialne On
Nai o( apptirant, ifMUate
Rame ol nwrtga9ee «contraU se0er �� �
qEpreu of mon9a9ee a mntrac� seDer (num end
qame p{ �g�¢e w oNer owner m hdder of mortgage
Address of assgnee (number aM suee4 �Y. s+efe. aM
Dces epplipnt own Woperty in any other
counryinlnCiana? ❑ Yes
p��p� aPP��� m� amount oE
zo_ p_
sg�cure d camry nue�wr
I/ We cert� u�er e pen af
'I oxmer I p!y(tra yer e aFw
,w�r ex��cea a�o�.�.
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person (numberam
-d �- ��- �.,�
: / Contraa IrWe6tetlness unpaid as
a�2nt yeer
wi� somewre aher Ihan
streeR ciry, s�ate. eM ZIP code)
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Z!P mOe)
�t yes, wnat muny+ wnat Ta�d`g
COUNTYAUDROR
zo_ zo_
that ihe above and foregoing infortnalion i
ned Droperty on date application is filed.
dty, stare,
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R¢coN number Page numErl
o3Cl �a O/
�mpaid as W Is Ne apd�!? �e s
Yes L1 No
xrlY in question: MnuelN hssr.ssed
P,operty ❑tvmua�yassessed
- /-/d /a �c
Has Ihis deduGion been rtQUested on propeny
for artent yeaf+ n Yrs ❑ No
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Dra�r�er NO....�0��......
ca�-a �.ro. .....30/�
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