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'°'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun shi
_ : FOR DEDUCTION FROM ASSESSED VALUATION
• State Form d3709 (R71 / 6-09)
� 1 Presvibed by Departrtierrt at Laml CmvemmerG France
File Mark
Q
INS7RUC7IONS: F� � _
To 6e filed in person w by mail wiN Ihe CountyAUditor or Counry RewNer o7 the tounry where the pioperty is located.
Filirg Dates: 7) Real Pmperty Must file during the year for which the deduction is sought �[] Counry. Auditor
2) Mo6ile / Manufactured Homes rrot assessed as Real Pmperty: Must file dunng the tweNe (12) months o�7 CS/S'�
before Maah 37 of each year the deduction is sought. 'L� ���v R�rder
See reverse ' e lor addifional inshuctions and qualifications. GI
App5mnt ornconvaab/yy// -see ' mreverse�s�ida�)� /��%
�JY�. LJ r %�/101/i_/�CJLXJ/
Y tEal qppMy as
1�
GY�/%.3o"�J�
ss unpaid as ot Mortgage / ContraU
tlate of appGtation
tt Ip. what is his / trer erap 5ha2 of intere5t7
tl name on rt.md is Cilferent ihan that ol appOCant, InEirate Eebw
Name W rtnrt�agee ar mntrad setler /J� � /^�
l° n "1 / �
C.. \TI
AEdr� of morn,7age� or mntraa se�er (number end sbeeL r�: sta�, ard LP code)
Name of assi�ee or oNv wmer or halder d monpaga
'_ ••�.�wmlee.(numher ar,C saee4 uA: smm. erd LP code)
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� DI'fl15'�I' 1�'�....�.7.`.11,l��.
Card 1\`O. ....p�,Q.�j(�
�r + ► 3
Sig�uture af CamN �itor
If owned wi� sornearre dhar llll�an
COUNN AUDITOR
zo � zo
Counry
unpai0 a d Is ihe eppfimnt Ne sde
�-y� legal w epuilade awne(.+
l�J n Yes n No
Is the properry in Question: Mnua%ASSesseE
I,] Real fhoperry ❑ Armualy Pssessed
Abdle Hane fIC 6
Has �his tledutlion Eeen requeste0 m pfoperty
for wrtent yea(.� � Yes ❑ I
zo I zo
I/ We certify under Ihe penalry of perjury that ihe above and (oregoing infortnation is We and cortect a�M �hat che appiinn[ is a resident o( Irdiana and
owner I mntrad buyer of ihe aforementioned property on date appluation is fiied.
�ruWre (ovme/s futl name) .. Date (monM, daY. MeA
Mtlress of auCrorrsetl person (number aM stree; dry, s+ate.
anC21PcUp)
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