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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun wn ' r
__ ; FOR DEDUCTION FROM ASSESSED VALUATION
� Sfate Fortn 43709 (R71 / 6-09)
�' � Prewibetl by �epartmenl of Local Govemment Firence
File Mark
INSTRUCTIONS:
To 6e lled in person w by mail vnth Ihe CountyAuditor or County Recorder o7 the county whe2 the property is located.
Filing Dates: i) Real Pmperty: Musf file dunng the year (or which fhe deduction is soughf. �Co n uditor
2) Mo6ile / Manufactured Homes rwt assessed as Real Property Musf file dunng the hvelve (12) months
before March 31 of each year the deduction rs snughL ����de�
See reversa side /o� adtlRional instmctions and qualificafions. G�BS '
Key
�������
Mamh 1. aaren[ year
If ro, what Is his / her exacc shara of interest?
�rrcye�uuu� % �O — D
-/a -/ -ao3-oo0. d-�
Mortgage / Contract intlebtetlness unpaid as of Mortgage / Contrad indel
Mamh 1, airtem year „,,, date of appG�ation
on recortl rs tlifterent Nan Nat of appticant, inAicate 6elow.
���
Mdres W rrortgagee w contrad se0er (number aM stree� cdy, sfate, arM
Name of assignee or other owner or hdder of rtprtgage
AdAress of assignee (number aM streeS �'. �+e, antl
lrant own yoperty in any �
IrWiana?
❑ Yes
Deeuction approved in the amount of.
20
Signature ot Counry Auditor
20 � 20
COUNTYAUDRO
20
Caunry
wiih mmeone other tl�an spouse,
� _
Remrti number q Page numbrJ
'�O� ! S��,j'
unpaiC as of Is ihe appliran[ Me mle
Yes U No
Is ihe property in question: Mnualy Assessed
❑ Rea� Roaertr ❑ nm,ua�ryn�essed
'Di•a�ver \O.. °�•I........
c��-a ��o. .....r'.a5�.....�..
,i�o �t�f,1� �
(' I
Date (month, day, yea�
�
2V _
I/ We certify under the penalry of perjury that ihe above and foregoing infortnalion is We and cortect arM that the applinnt is a resident of Indiana and
owner I mntrad buyer of the aforementioned property on date application is filed. ' �
InaLire (o�meh /ull rum� , ' Date (monfh. tlaY. l'ea�
a�M
yea�
Address of authaved person (number aiM street �ry: state, arN Z!P code)