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" STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownshi vear
,_, FOR DEDUCTION FROM ASSESSED VALUATION � ��
StaEe Fortn 13709 (R70 /11-08)
��.0 � Rasaibetl bY �Nrenl d Loral GwernmeM Frt�anm
iNSrnucnoNS: Mq����M��009
To be lled in persm a by mad witfr fhe CounfyAudito! d fhe oounty where the poperty is located.
Filiig Dates: 1) Reel PropeAy: Musf fde during fhe ye&rloi wh6G� Ne deduction is soughf.
2) Mobde / Mamifecturetl Nomes not assessed as Real Properfy: Must file tlurrzg tl�e hveHe (12) months
the dedwction is sovght
See raverse side for addAional inshuUiorts and qualifications
App&anl (oMn mNraci Mrytr- seem��sb(�/s m sidn) /
. /� [L.%�/�i. / T / � Q �CJ
a�vmo
Ma�ch 1, airteN yea
tl ro. what is h¢ / her eratl shaa o(
C(ame m ieco�d'¢ Q�erem lhan ih� or aVG�l iMim� baiw:.
Name d mutgagee v m'Erar� se0er ,
i�
Aedress d mo�agee v canract seAer G
Nama a( a559riae w oAm owrier v Mab�
nna�ss a aRq�ee c�umae� aa mea.
Dw• aPpGmnt own propBrty in anY a7hBr
murrtymlMFareT � Yes
Deducfian aGO�oved in Ihe ama�M af.
NI U� I 20
cty, stam,
No
�Y.
- 60/ / �� -O� �
IebleEness unpaid as d Matgapa / Q
��
year
I �egal a��e�l
YY� Yes ❑ No
so«3b, udkate..;ui wt�wn �
�5 BP(OpBfryY1QUB5�l0lI:i1M113�'%1S5B55Bd
Real Praperty Q MnualtyAsseaed
z�P�o> llra��•cr i\'O...c��9
.....1........
H yes, what a
�������o. . aa9a
�� � � y</ 5. °°
�'/
20 20 20 � _�
Gion baen rapuasted on pmperty
3n ❑ Yes ❑ No
Y��)
FI7
I I We certi(y under the penalty of perjury ihat the above arW foregdng mfortnatbn is We arW correu and that the appiicant is a resiGent of InOiana aM
awner I contrad buyer of U�e afarementbned pfoperty on date appli<ation is filed.
7uatyre (awrmfs RID naipe) �ate (monP�. QaY• Y��)
Add`asa d aNhvized parsm (num6ar aW sLeet, rity, sbfe. antl LP cotle)
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