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'°+ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun T nshi Y r
__ , FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn C3709 (R11 / 6-09)
�' �resaibed by Departrtren[ of Lacal Govemment Fi�ance
f�(
�STRUCTIONS:
Fam 1�eda
To be �Ied in person or by mail wifh the CountyAUdito� or Counry Recorder o/ the counry where the poperty is located.
Fil'mg Dates: 1) Real Pmperty: Must file during the year Por which the deducUon is soughL Cou Ai�or
2) Mo 6i fe / Man u f a c t u re d H o m e s n o t a s s e s s e d a s R e a l P r a p e r t y M u s t fi I e d u n n g t h e I w e N e ( 7 2) m o n t h s ,
before Ma�ch 31 oteach year the deducfion is srought. G I B 0 OU'`�'o�iKt� '�eo��4
See reverse side lor additional instruclions and qua/ficafions.
AppWant (owneror � see rererse s"xie) � �
A�sed rahre d real popertY as ol
MarM 1, ar�e�rt year
tt ro, what ¢ his! Icer e�mU sliare of inte
If rame m mmd is OiiFerent tlun Mal o
Name of mortgagee a mntraU sH�er
Addfess of mongagce a mntrad seAer
Name of assi�ee w other owner or hd
r / legal Eesaiption '
� -o�-�oa � 3 yao o a
Mortgage / ContraG iMe6tr�ness unpaid as d Mong
Martl� 1. artent year date c
ranL tr�difate beb�r.
irsand ;ciry.�
mortgage
(number aM streeC rny, sfate,
Does epplimnt ovm WoPertY
counry in IM'ana? r
L'i9
Sigretlne
appmvcd'm Ne artnunt oE
�
I If yes. what munt7/1 I VJhat Ta
No
couHrvnuorto
20 20
bnWness unPaid as d I Is Ne ePP��� the sok '
kgal w equitade ovmeR
❑ Yes ❑ No
spouse, indicate with xiwm
Is tl�e P�GenY in Cuestion: MnueAyl�sesse0
�ieal Pmpenv ❑ i4muaM Assessed
n���„����.o. a�.►a....... -
, b
Ca rd \ O. .. . �. �. �.�. .I ... ..... . -
. I Date (rtmlh. daY. Y��l
20
I I We certify u�der the penalty of perjury that Ne above and foregdng infortnatian is W e and corteG and that the appiinnt is a resident of I�iana aM
owner I contract buver ot the afaemertbw�ed property ai date applicatlon is filed.
� I Fu0 revtl�t adCFesS of anW'�nr�(/L � 4 aly e�� n
/1 / � /� / � /J
rf9 /</ i T ii�
Pei:m autl�oraeE Gy dWy ezearted Pawer of Attomey rn by IC 61.7
Pddress W aWwmed person (numberand sbee4 �Y. state. aid LP code)
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