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"' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C n T hi ear
_ : FOR DEDUCTION FROM ASSESSED VALUATION
• � � State Form 43709 (R77 / 6-09)
�' w. � Presaibed by Deparvne�n W Local GovemmeM F(w�ce
wsrnucnoNS:
DECF�� ^�`�01U
To be fiied in person w by mail with the CounryAuditor or Counry Recorder of the counry where the property is located. F� �� ��
Fitirg Dates: 7) Real PropeRy: Must fik dunng Ne }rear for which the detluction is soughL � 18,�(��yinry quditor
2) Mobile / Manufactured Homes �rot assessed as Real Pioperty Must file during the hvelve (72) rtronNs d�u�tvRecord
beforeMarch37ofeachyearthedeductionisso�ght. QIBSONCO�Y�ylJUl7c�p �
See /evfrse side for addifional inshuclions arM qualifications.
�ADP�f(ownerormnLaCbuytr-seerest2ctiwumreeer�4side) n
naPSUtl vaac a ma� Ropercy as a
Matrh 1, tl�mLL year
1
�i M. Wtldi 6 �16 � �IEf P.XdCi 5�12f8 0� �I
If rwrie m 2cnd'a EiRerent than tlu
Name W rtwrtpagee m m�trarl se�er
Addtess o( nart9a9ce w wntraa sell
Name of assignee w oNu awner or h
Der/IegalCesvip
- a-o -
��a��
50eeL �Y• 5tete,
li`ant wm yoperty in any
Indaria?
❑ Yes
Deduction approved In ihe amount ot
�
sig�an,re or co�mn awrtar
�_
IR7
� cifl: 9ate, ard:
�
IPOOde)
res..N,ai m��c�r
_oai. �s/�/-6a�'
]�MSS unp2iE az of Mortpage / (
SWf1EOfIC Oi�IBf I�13l1
-/o
VJhat Tarirq Distrirl?
numhc
oroio � �i
��b�� �������
7� Ie�i w e�uftaWe ow�reh
:JV n Yes ❑ No
Is tlu DroDeRY in Qurstlon: MnueOy Ass�ssed
❑ Real PruPenY ❑ ���Y �
0.bble F�krtie QC G7.
��� � �1 o�d
r� u,� a�a� t� aau��ed o� v�r
tor dumnt yea(.� f'1 .,_ _ i-'1 ..
Na y�� vA� � �
p
O� 0/D— �J'�� 7 3y.,��
I/ We certify u�er Ne penalty of perjury that the ahove and foregoir
v.mer I mntraU buyer of ihe afaemenGOned property on date appli[
(numDer antl sLeet, cit}; state, ard
Atldress of aWialzed 7�+ (numDeraM sneet u+Y. stata, an0 LP cade)
xident of Indiana ard
�r. r�n
Da[e (ma+fh. tlaY. le�