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^'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
__ _; FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R71 / 6�09)
�` �` Prespibed Gy DepaNrrenl of Loml Govemrtrenl Fnaxe
INSTRUCTIONS:
k 6e filed in person w by mail with the CountyAuditor or County Recorder of the county where lhe property is lo&���N
Frtng Dates: 7) Real PropeRy: M�st file dunig fhe year for which the deduction is sought.
2) Mobile / Manufactured Homes not assessed as Real PmpeRy: Must file dunng the twehre (12) monfhs
before March 31 of each year the deduction is sought.
See reverse side for addi[ional instrucfbns and qualfirations_
App�orit (fo�'� rar contrart buyer - see resfirb�ons rn reverse side)
� .LI/�2./.inatL��o — - -
I'a�i^9�trat • _ F(e1' number / le9al deSaiP�n Rec
ed value d 2al PmpstY a
i. ar�ent ye�ar
name on
u�din[e below:
Addtess of mortgagee a mntraa se0er (number an
Name of assi9nee w ottrer owner or hdder of mortg
AdEmss of asvgnee (number aM sbee; tlty, state,
Does applinnt wm pmperty in any o�her
munryinlndiana? ❑ No
❑ Yes
ction aOD�� � � amount oE
�o_ 20
cdy, state, arM ZIP code)
� County Audrtor
❑ County Recorder
number
�qage I Contraci indebted�ress unpaiC as of I Is Ne applkant Me sole
: o( application kgal m equttade oxneR
❑ Yes ❑ No
someone other ihan spouse, indicate wM whom
�I the property in qurstion: MnuaM Assessed
teal PmPertY ❑ �!!�h'.� . . _
If Yes. what counry? �—"'^m DistruY? Has iha dedwlion Eeen requeSteA m P��Y
fm amem yraR ❑
�p2� - ❑��
COUNTY �i�.S.��J m
Zo za _ ��1�' � S5
zo
Sigrahrte of Couniy Aud'Rw I�.u...-. r. r�n
I I We cerirfy uMer the penalty of perjury ihat Ne above arW foregoing infortnalion is We and cortect and ihat o�.. _, :sident of IrWiana and
owner I mntrad buyer of Ne afwemerrtioned property on date appliratlon is filed.
re (o /ull+�ame ' Date (monfh, day, ysa�
��� �� � �,�<
FWI residenrt_adCress o� pp�)ant(numberar�d shee4 �Y, �leI,-and ZIP �� ^
� �U � i �-' - 0.\c � 'c 'C' V� U
Pason authorized by Euty exewted Pawera(Aitorney or by IC G7.1-12-0.7 Da1e (rtronlh, daY, i��
AEdress of autlior'vEtl person (number arM sbae; dry, sYdte, aM ZIP code) .