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^'+ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
___ _� FOR DEDUCTION FROM ASSESSED VALUATION
• State Fwm 43709 (R71 ! 6-09)
�' � 1 presrnp¢E py OepartmeM of Lncal Govemment Firence
�STRUCTIONS: f
To 6e filed in person w by mail vn[h fhe CountyAuditw or Counry RecoNer of the county where the properry is located. ���ZQ,�
F7ing Dates: f) Real Property: Must file durirg the year (or which the deduction is soughL � CouMy ditor
2J Mo6de / Manufactuied Homes rwt assessed as Real Properfy Must fife dunng the twelve (72) months , ry� —�,._
before March 31 0/ each year the deduction is sought. �L� �
See reverse side lor adddional instmcUons and qualifications. G
Mp�xam rucanMan6(y/yer-���/n/�e� mre.9rse � �% /y� R
�i ii0 . V �� !// �� j �% /1Y (/ ^� ..
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poper:y a W
rw, what is his / her exan share ot inferes�?
name on �emrd'a diRe2nt Nan that of aPpl
_ �,_ _�,
Abriga9e / Cantraa'v
Mart�h 1. curten[ yrar
Nartre ot rt�oRgagee a rnntrati sHler i/ ����/�
�i�
Oress of rtaRgagee or cmtra�l se0er (nurt�i er end streel, crty, e. erN 2
Nanie of assi�ee or other owner w hdder ot mortgage
Add2ss ot assgnce (rwmber aM stree4 �#Y. ffi�. and ZIP ootle) -
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Oces apptiranl wm pmp�ty in any a�hu If yes, whal muntyl
counbl m InEiana? r-� _. r-i ..
� Remrd numbu
-G'�. �. Do3 � O Q /�
ar�ss unvaid as ot Monaaae I Contra�'uNebtetlness �moaid as W I
dtaGle axfreY.�
Yes ❑ No
If wmed wiN someone other ttan spouse, iMicate wM wfwm
I5 t property in queSGm: MnuaOy Assesu-0
Real PruPeRY ❑ ���Y �
Moble Home (IC 6
Da7uctianaDW�InUieamountof. _ _ ____
20 _ p p -
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$igriature 01 Camb AW itor
v,�������- �;o........
an� ........
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20 _
I/ We certify undv ihe penalty of perjury that the above anA foreg t a� O ,,.. �• a resident of Indiara arW
owner I conVaa buyer of th forementioned property on date apF C c`l
SigreLUe !u➢ na i _ Date (rtronfi. EaY. MaA
Z'�O� ��Y(oK f-l-(/t �/�'��{f�.�.
Pelsan auNwrzetl by EWy execuud Power ol Attomey or by IC 61.1-72-0.7
Pdd2ss of authoraetl persw� (numberaM sbeef. dry, state, and ZIP catle)
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