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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
__,_ FOR DEDUCTION FROM ASSESSED VALUATION
� State Form 43709 (R71 / 6-09)
,,w ' Presaihetl by DepartmeM o( Laal GovemrtreM Finance
File Mark
wsrRUCnorvs: M
b be lled in person w by mail with fhe CounryAUditor or Counry Recorder o( fhe county where tAe pioperty is located.
Fil'mg Dates: 7J Real PropeRy: Must file during the year for which Ihe deduction is soughL w Auditor
2) Mo6de / Manufactured Homes iat assessed as Real Property: Must file dunng the hveNe (12J monNs C' ' ry
6efore March 37 of each year Ne deducfion is mught. ry Recorder
Seereversesidetoradditiunalinswctionsandqualifications. GIBSON UDITOR
AvNrcantlowrerorroitract6uver-tee25inc0aisonreversesidel_ . . '
Tad Oistr¢t�/ Key rwmGer / legal desaiption V Reco�d number Page numbef
� a�-rz-o�-�,o�_oa�..aa�-o�8 �oo� a.r�
Asrssed rWue M mal poperty as d Mort9a9e / Contraa intle6tedness unpaid as W h/origage I Cantra`Y citlebtetlness imG� as d Is Ne eGD�� Me sok
March 1, amm ym Mar� t. a�rtem year date of aDP�� � a eW ��e �
I 8� DDD ❑res ❑No
If �ro, what'r¢ t6s / her exatl share of inta�?
ro
m
of rtnrtgagee or mnttxt seller
PDd2ss of nnrtgagee or cvnbad se�er (number end sheeC �',
Name of azsignee w other owner or holder ot rmtgage
Address ot atsi�ee (number an0 svee�iry, slate, antl
any
No
Deeuction appoved in Me amount af.
�.
20 _ � 20 — � 20
��pire U Camh Autlitnr /�/�/�
C .T.
I I We certify uMer Ne penalry of perj Nat Ne
oxmer / mntrac[ buyer of the aforementioned pro
by dWy executeC Power
�, aM ZIP code)
/ �
H owned wiN somewie other than spouse, i�irate wNh wlwm
Is tM praperty m puation: MnuaOy Assessetl
[}}Real ProPertY ❑ Mnually P�
Te �^,/
DI'81�'C'1' �i0.!�,���....... ❑ No
GOUNTYAUDRC ��I'� �ro. ... ya r.7..�....
� �Cn�`IDO.o
ZO_ , ___ � N_ � [U
Caunry
Dale (rtanlh. daY. YEa�
fiA foregdng infortnalion is We and cortect and ihat Ne applkant is a resident of IMiana and
date apPlicatlon is filed.
Date (morrth, day, yea�
arM LP catle)
person (numbereM snee4 �%% slate. an0 LP code)
Date (monN, OaY• Yea)