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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
__ POR DEDUCTION FROM ASSESSED VALUATION ag
_ .. • State Fortn d3709 (R11 / 6�9) � � � �
�' � Presvibe0 M cePe�M o( Lacal Govemment Finance C
� � File Mark
INSTRUCTIONS: A �n'��'
To 6e filed in person w by mail with the CounryAUditor or County Recorder o/ the county �+� tl� �o�yys bcated.
FiNng Dafes: 1) Real PropeRy Must file durirg the year for which the deduction is soughL
2) Mobile /Manufectured Homes rrot assessed as Real PropeRy Must fiie �rin��2) months
6ePore March 31 of each year the deduction is sought.
See reverse side fo`ddtl' "onal instnictbns arM qual�icafions.
App6rant ( buyEr - `erse side)
T isbi ` Key�wmCn/ I esaiPtion
� �� —Ol
A�essed value d2al O�Y aa ol . MwNage / Contre�
\MaU 1. armit year Mamh t, wrte�t y
tt ro, what is his / htt euct share ol interest?
If nama on 2ooN's dAferen[ Nan that ot aPpl
Name m mortuaaea «mntxt se4u
� •• ��� �I �
Form t�ed wiN'
�unry Auditor
❑ County Recorder
etlness unpaid as of Morigage / ConvaC ude6tedriess �mpaid as d Is Ne eppfi�nt ihe sok
date of appGfation �gal pr ¢QUitaEle owneY7
O O� ❑ Yes ❑ No
H awned with somearre ather Ihan sPOUSe. iMxate wBh Mam
of mMgagee a rontrad se0er (number and straef, ci(y, 5ste. aM ZIP code)
Name at assignee or Wier owner w tdder of morigage
AOOress of asvgnea (number aM atree{ rdy, slafi.
Dces a�iraN oxn 7�P�Y in any
munty m �ndi2lla? 1"1 ..
c6on appmved'ui Ihe amount ot
20 _ 20
d Cacriy nuaaor
20
Is tM V�7�Y in Ouestion: Mm�eOy Assessed
❑ Real Roperty ❑ ArmUally Pssessed
������1' �r
/ O
..�%C/_�.(��1 � m prpppny
C�!'Cl l\ �O . S ' Y.� es ❑ No
� �n
COUNTY AUDITOn �� ' `�'7/_
i tiCl
�,/�1 .
�v ����
20 20 _ �
Caunry Date (rtnNn. daY• Y��)
1/ We certify untler the penalty of perjury Ihat Ne above and (oregoing informalion is We and mrtect arW Nat Ne applirant is a resident of IrMiana arW
awner / contrad buyer ot ihe afotemenlioned pmperty on date application is filed.
y6�i '{pwneGi MI name� _ _.. Date (nmCi, tlaY. Y��)
autlwftrN Dy
sLaet. aq: stare. arM
person (numberantl sbeef. city. sfate. antl ZlPmdc)