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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
_, : FOR DEDUCTION FROM ASSESSED VALUATION
• S1ate Fortn 03709 (R71 / 6-09)
, j P2saibeC ty DePartmeM of Loml Govemment Frence
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INSTRUCTIONS:
7o be filed in person or by mail wiN the CountyAudifor or Counry Remrder of the county whe2 the pmperty is located.
F7irg Dates: i) Real Proparty: Must file during the }rear for which Ihe deducfion is sought.
2) Mobde / Manufactu2d Homes rrot assessed as Real Properfy Musf file dunrg fhe tweNe (72) months
6efore Ma�ch 37 of each year the deducfion is sought.
See reverse side la additional insWCfnons and qual�cafions.
P�L
� re� @nDe�b as
1�
tl no, wha� Is his / Mr erad share
If name m �emN is dEFemnt ihan that o( a0pbani, u�Ei�ate Eelow
Name of mortgagee w mntrad seller
PdAress W mort9a9� w oontract se�er (nim�Der entl sbee4 �', stete.
Name oi assignee w other owner or hdder ot mwigage
AACress of assignee (number arM street my. slate, and ZIP wCe)
Does aPD�itant own ryoperty in any olher If ye5. what cc
munry in IMena?
❑ Yes ❑ No
�
1 �i7n� Audhw
-�oGnC� Recorder
kgal u equRatle aMneR
❑ Yes ❑ No
tt wmed wiCi someo� aher ihan spouse, irWifate wNh wlwm
1M�at Tadrg
Is Me D�DeM in Guestion: Mm�aOy Assvsud
� Real Property ❑ AMUally ASSesSed
�.F:l�i
COUNTYAUDROR
Dgluction appmaed in ihe amount of.
ZO 2p _ 20 _ 20 20 20 _ 20
Signanne ot Counb nwitw Counry Date (monM. day, YeeA
1/ We certify under Ne penalry ot perjury thai Ne above aM foregoing infortnation is W e and cortect arM Nat the applinn[ is a resident of Indiana aM
owner I oontract buyer of the afaementioned property on date apP���n is filed.
�reWre,(ownef: futl name) Date (monfi, daY. YaaA
\
�sident a m6er antl 4�'+4: �te. and L ' ' ..
P uthoraetl by dWy esew Power dHttomeY a M IC F1.f-72-0.7 Date (nm�h. tlay. }ea�
Atltlress of author'¢etl persan (number aM sLee4 �'. ��e, antl LP code) _