Mortgage_Adams (3)�"� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ FOR DEDUCTION FROM ASSESSED VALUATION
State Form C3709 (Rit / 6-09)
`,,,, � Pfesmbetl M DeGartncN of tn�l GovemmeM Fi`wrn
� Fil rk
INSTRUCTIONS:
b be filed in person or by mail with fhe CounryAuditor or Counry Recorder of the counry where the poperty � t F
Fifing Dates: 7J Real Property: Must file durirg Ne year fir which the deduction is soughG Counry Auditor
2) Mo6de /Manufadured Homes rat assessed as Real Pruperty Must file durv�g the fweNe (12) rtan
u'iV1AR i LL�nryRecorder
befwe March 31 ot each yaar the deduUion is swght.
See reverse siCe for addifione! insWCf(ons end qualfications.
App�iwm (pwrpror mntrarl buyxr- see rps(rirliqqs m rererse si0e) 6.� �
SI�a I Mf e�ut�l st�a�e of Inte�esC/
remd is dRerent Wn ttut W aGP��L ind'xate Eelmr.
W me of rtnrtgagee or mntract seller
Dces aPplirant own property in eny oMer
countyinln0iana? ❑ Yes
ra�•
.ffi�,
tlty; smte. antl LP catle)
,��.�����
❑ No
0
_ oo/. � �� -oa� �'"°o'� �
s unpaW as W Mwtgaga / Contraa inOebtednnss unpak as af b
aar� a aaar�n� �
� UUU
Wlat Tarifg D'atric
v� u No
k pmpertY m Que�an: MmieM R•sseueE
Rr21 PtopCrty Q Nulually PssesSed
e.wn�� r� nc ��.
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Drawer \'O..C��.f,�,.,,.,.
I170 I
Card NO. .................
�.�,�_� ��y'�,959 ��'�
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zo _ 20 _ zo zo _ zo zo _ zo _
SigreWre of Camb Auditw Caunry Date (monN. daY. Y'��)
I/ We certify uMer the penatty W perjury that Ne above and (oregang intwmation is true and correct and that Me applinnt is a resident o! Indiana and
owner I contract buyer of Ne aforementioned property an date apDlication is filed. �
� SignaWre (ownefs hAname) Date (month, deY. Y�A
FW �sident of appGrant (numEer arM street �.�ce. arE ZIP cotle)
� / . a.ta.. � ' � 7c% %�
wttqi¢etl by dWy azecutetl Power of AuorneY � M IC 61.1-12-0.7 Da�e (monN. OaY. Y��
ot auCro�treA pasan (numbef aM sfreat �: sfate. anC LP code) .
