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.f.�•n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS To p Year
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= FOR DEDUCTION FROM ASSESSED VALUATION
' State form 43709 (R8 / 207)
�9�� •O Prrsa3ed by Departmen� of Local Govemmenl Firunca � 4 2��8
Fite Mark
INSTRUC770NS: ,/y� �,�/ _
To be filed in person or by mai7 wdb the CountyAuditor o7 the county where fhe propeRy is located. O"� � ''����
Fding Dates: 7J Real Property: Dunng the 12 rtronths 6e(ore June 77 0l the year the deduction is to be eflective. V
2) Mobile Homes assessed under IC 6-1.1-7: Befween Janvary 15 and March 2 0( fhe year fhe deducti�oi�� �i�i��Y AUD170R
See 2verse side for addifional instructions and qualifiwtions.
w mnGad
real popaty as aF
sea
Key numbe//legal desrriplan �q C / � p
- `, ' � �Q ' [/Q Q. J (O S —Q �O
3rU 1. arrent yeer Abngage / ContraG indebtedness unpaid as of March 1.
�R�t �� ti 3 S i a-
�, what is his / ha e:aU share of inlerest?
If reme m record is ddfereN than that of applinn4 ��ipte Delow:
Name of morigagee or canU-dcl e� � � `i,' w`^"" J'�
_ C��. ui
Adtlress of rt�ilgagec « Uad seller (number and shee( dty, sta(e, and ZIP crotle)
Name of assgnee u Wmr awner w holder of mongage
Adtlress of assignee (rnmMei arM slreet, dty, sfafe, arW ZIP cotle)
Dces applicant oxn property in arry olher If yes, whal wunry7
caunty in Intliana? �
❑ Yes ❑ No
Deduction appro+ed in Ihe amounl oF.
20
SyreWre of Caunrylw0i�or
20 _ � 20 _
RemN
someane dlier lhan spouse. intlicate wilh whom.
x equilaMe o.me%+
❑ Yes ❑ No
Is the praperty in quastion:
❑ Real Pmperty ' � Mobile Home
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— Dra�ver NO.�Q�:: .��. �.
Wha� Ta
� Card i�'O. .� ...................
i�`,�" �3 2�a.va
couNTV auoiTC ,
20 20
Counry
20
d on property
e5 a No
Date (monlh, day, yea�
20
I/ We cerlify under [he penalty of perjury tliat the above and foregoing information is We and coRecl and Ihat tlie applicants was / were a resident of
Indiana and owner of 1he atorementioned property on March 7, 20 _
%OG� W , Of"/�[G
Person aullar¢ed by duly erze
Address of aNld¢ed �erson
rm6ei and , city. sfate, ai
,e i,✓e���✓,
Power of NbmeY a�' IC 61
aM sheel, ary. s(ate.
code)
Date (month, tlay, yea�
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