Mortgage_Chamberlain (4)�"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R8 / 2-07)
�� y�� ` R�aibed by Deparimenl of Loral Govemment Firance
File MaAc
INSTRUCTIONS:
To be filed in person or by maB with fhe CountyAuditor W the courtfy where the property is located. ��f L � � 2��8
Fd'a�g Dates: 1) Real Propeity.' Dunng the 12 months be(ore June 71 W the year the deduction is to be elfective.
2) Mobile Homes assessed under IC 6-1.7-7: BeAreen January 15 and March 2 of fhe year the deducUon is fo b� e8ecfive/.1[!��
See reverse side !a additiorral instructions aiM qualifications. �6� �"'+""�
(owner ar wnhad
his I her ezacl share
if reme m recwd
m
�y �wmber I legal desaiption RecoN numbe Paqe mimber
- � -as- o�- o. �°r-aao o ��o
of Mardi 1, arrerrt y�r AAwtgage / CorNaG indeWedness unpaid as of March 1, Is Ihe app5mnt Ihe sde legal a equitade o�meR
wrrenl year � O
❑Yes ❑No
of inleresl? If wmed wRh someone ather than spcwse. indrate wi�h whom.
Ihat of applican4 i�mle below: Is Ihe propeAy in question:
❑ R�I Property ❑ Mobile Hare QC G7.1
seller
Adtlress ot mortgagee w mnUad seller (numberand sLeet, tity, slafe.
Name of assi9nee w dlwa o.vner « holder
AdNess of asvgnea (iwm6� and sfreet, ti
Dces applicanf o.m property in arry dher
counry in India�?
❑Yes ❑No
Oeduction appmved in �he amwnl ot:
20 � 20 _
Sy�Wreof unryAuddnr
andZlPwde) . -
If � � O y � I�6 � Has Ihs dedudion been repues�ed on property
p . • fwwrrentyeaR
TO�•"' ❑Yes �No
Dra���cr l\
— —
,�' C�l"(i ti�• .....................
20 _'_ � �u _ I 20 20 20
Counry
Date (month. EaY. yea�
I I We certify under ihe penalty of perjury that ihe above and foregoing infortnation is we and mrrect and Ihat the apptinnts was I were a residenl of
Indiana and owner of the afwementioned property on March 7, 20
�at�ue (o�yne/s MI neme) . � � Date (monN. tlaY• Yea�
cdy. state. arM ZIP mtle)
Allamey or by IC 61.
Date (rtronth. day. Yean
pelsm (nwnberarMs4ee4m8slale,aiMLlYOOOe) _ ,