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^�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou shi Year
FOR DEDUCTION FROM ASSESSED VALUATION
7r-' . .• Slate Form43709IR11 /6O9)
S 1 p�ipyd py pepartrtcent otLaW Govemment Fuiance
m.
File Mark
�STRUCTIONS:
ortn e ' .
To 6e filed in person or 6y mail with the CountyAUditor or Counry Recorder of the county where the property is located.
Filing Dates: i) Real Pmperty: Must fite dunng the year (or which the deduction is soughf. ��. Auditor
2) Mobde / Manufectumd Homes not assessed as Real Property Must file dunng the twelve (72) months ❑
6efore March 37 of each year the deduction is sought � �ef
GIBSO
See 2vers ide !or addit"vnsl instructAons and qualfications.
Appfrcant(o rJortantraGbyrer-see(�\vr/l�'ns m�7renverseside) f ./ .
_ YiA /Y /�' � \ 1�--//�LYi.i ) � Il /�i/r�J _
af real 7�ro�nY as of
wfiat is his / Mr e�G share of
If name on �ecortl's dAluent lhan Nal
Name oi mmgagee or cmtract se�er
r����.�
�
u�Cirate Cebw.
rtqRgag� w cantrsd se�er (nurriber end s0ee4 �Y. �te,
w oiher owner or hdder ot mortgage
oi assignee (nurtr6er arxl streeG my, slate. an0 ZIP oode)
Does applitant own poperty in any ot�er
counry in Indiana? � Yes ❑ No
I
DeaucGOn approved'u� tl�e amount oF:
IF yes. what count�/.�
D Ovj. o�a -Qo� e�
ss unpaid as o( Mrntgage / CmtraG u
zo_ � zo_ � zo_ � zo_
If owned with someo� othu
ru�mbrl � Pape numbu
��Gaid as o( I Is Ihe ePP�� the sde
legal w epuitable awneY.�
n Yes ❑ No
P��PenY m VuesCac MnuaOY Assessed
'31 PmPehY ❑ ArmuaOY Asussed
Modle Home (IC 6
Has Iha deduaion Deen requesteE m pmpeJty
for w�rent yea(! ❑ Yes ❑
DraiverNQ..°?�,�a........ zo_
� �_
Card I�'p, °Z17-f „Y,,�„�
.....................
I I We certify under Ne penalry of perjury that Ne above and foregoing ir - ��� �� •� resident of Indiana antl
owner I contract buyer ot the aforemenlioned property nn date apDlicati�� �....._ _
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L�r.:t
stare, antl
ciry, state. an0 ZIP code)
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