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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship vear
__,. = FOR DEDUCTION FROM ASSESSED VALUATION
• Sla[e Form 0.i709 (Rt 7/ 6-09)
,,�,� � Presai�ed by DePa�rR af Loml Cawemment Fi�nce
Fil
INSTRUCTIONS:
To be filed in person or by mad wiN the CountyAuditor or Coun Recoider o! Ne coun where the F�
Rfig Dates: 1) Real Property: Mus[ file du ' Ihe ry ty ��� ��t�
mrg year for which the deduction is soughL Cp�o �d�l U
2) MobAe / Manulactured Homes rwt assessed as Real Property: Must file dunng the hveNe (72) rtwnths I''I
be(ae March 37 0/ each yeer the deduction is sought. L=1, Counry Recorder
./�7
See 2verse side (or additional inshuctiw�s and qualificafions. ' �
ncp�(o»ne.oroonnauauye�-see�estrirto�rsmre.erseside) , . n _ u A I O
Assc� rdhie of real ptape�ty as ot
Me�tli 1. al�Mt IRaf
H ro, what is his / trer e�md share at intarast?
!f nane m 2md is drtterent than ihat o/ appl
"C/ /� T��
� / Contraa indebtedness �
airtentyeer
1 az W MlMgage / Conbact inOebteAness unpaiC a d I Is Ihe appl'xant the sde
date of appGfation legal or eQUitade oxneYl
❑ Yes ❑ No
If awnetl wiN somrane Wim Ihan spwse. NGKate wiN whom
Is tM property in Ouestion: MnuaM 0.ssessed
Real ProPeKY � ?!m!�M�??� . . .
Md� d rtnrtgagee a conbaG seder ( nd sheeG uN. sm�. ard LPcode) � ,
Name of assignee w oNer owner ar hdder of `mrt9a9e — . ' _ _. . . ..' . - —
MGress at azdgnee (numbare/d streeG �; state. �
1
DOCS B�I�l1l OMI pfOpEf�Y V1311Y OI�IM i �O I O 35 U16 4GdUCLM �BCl1 f2Q11f51C4 0!I pfOP2flY
oomuy m Intlana? ❑ Yes ❑ No D l� `d1i' C 1' � O . . .. . . . . . . . . . . . . . .. r airern yeaR
❑ Yes ❑ I
Card NO. � Osa
DeEud'mn app�ored'v� IFre anoura of:
20 _ 20 _ 20 _ 20 _ 20 20 _ 2b _
��hae U Camry AuOitnr Caumy Date (morvh. EaY• Y��
I/ We certify �Mer Ne penalry of perjury that the above ard toregoing infortnalion is We end cortecl arW ihat the applinnt is a residerrt of Indiana a(ul
v.mer I wntraa buyer of the aforemeMioned property on date application is filed.
�riawre (ox„ers rw wA ) O /l oate (mmm. ear. we�i
Peison aufhorized by Euty esi
y f 1 E� c�va.�
aea� a aNno�a�a �m
nd sLaeL �: �le. and LP oode)
1([�ttomeY � q' IC 1.742-07
��
�- �� nc n �
streeS dry, stale. entl ZIP oode)
Date (monlh, tlaY. Y�A
3�4'�J�o���
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