Mortgage_Fox (3)^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ . FOR DEDUCTION FROM ASSESSED VALUATION
• Sfate Form 43709 (R71 / 6-09)
S > P�rsrnLeE M OePartmeM of L.oal GovemmeM Firenca
File Mark
wsrnucnoNS: O,Z
Fortn th:
To 6e filed in person w 6y mail wifh the CountyAuditw or Counry Remrder o/ the counry where the property is located.
Fil"mg Dates: i) Real Pmperty: Must file during fhe year for which the deduclion is sought. u imr
2) Mobde /Manulactuied Homes not assessed as Real Property: Must file dunng the IweNe (72) months '��
bePore March 37 0l each year the deduction is sought ❑ County er
See reverse side 7or addRional instrucWns and qualificatbns. COUNTY a i i n iT.,�
I value d � O�P�Y � �
amem year
3l IS hi5 / h2! BYdfl Sh2fE O( YIfCf¢SI?
- �i-�o� - v... - ,�..�.,. c� . �
Mortgape / ContraG iMehtetlnrss unpaitl as of Morl
Mard� 7. artent yrar date
�ama m remrd a QAfuent than Nat o1 aPP�^L mdicate Cebvr.
Name of mmgagee a
Add2a o1 rtnrtgagee or oontraU seAer (nwMer aM sbee{ ray, state. aM ZIP cade)
owner or holder ot mw[gage
assignee (numher and stree; dty, slate. and ZIP
Dces aPpliwn own poperty in any oUer
munry m Intl2na? f'l .,' _
zo
Sig�uwre W Camry
�t o+mee with
i Recoid numbu Page num
-o�� aG��- 3 3
)age /C,ontra� ed��5 unpxid as of Is Ihe epplioni Ne sde
of ap � atmi�n d i(/U� �egal or equrtade amM
� $ ❑ Yes ❑ No
ameorie r ihan soouse. ind¢are with wfam
� wW�m �� a�,:,N�M r�ssessea
Real Proaertv ❑ AnnuaMA�s.sed
MoW7e Fiort�e fIC G1.1
Has ih's aedudion Eeen re9uested m v�Y
tor wirent Y�r? ❑ Yes ❑ No
COUNTVAUDROR
����� — - —
�_ i Zo i zo
c«
1 I We certify under Ne penalry of perjury [hat the above aM foregoing iMortnali�
owner I cantract buyer ot the afo meMbned properry on date application is filec.
� Sigranue (owne/s /u� )
FW � ent atltlrnss of ` t(number and aly, slate, and ZIP ootl
��a08 5�' i�venue �r�n(�P
, rson auflror�d by Ouly exeated Pawer of Anorney rn Cy IC 61.1-12-0.7
Pddress of authorrzed persai (number arM sbee; crry, sfafe,
llra�t�cr !\�0..... �Q.�.a.....
Card \'O. ......�;�J�
I oate (rtiorm�. w.y. �e
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