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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C n ip Year
__ FOR DEDUCTION FROM ASSESSED VALUATION
Sfata Fortn 43709 (R11 / 6-09) .
�' y„ � Plesvibed bY OepartmeM of Latal Govemmant Frence '
F rk
INSTRUCTIONS:
b be filed in person w by mail with tha County Auditor w Counry Recorder of Ne counry where the property is locafe�„ F� �� ��
Fi7ing Dates: 7) Real Property: Must file durirg the year for which the deduction is sought. ���a"� Counry Auditor
2) Mobde / Manufaduied Homes rpt assessed as Real Property: Must file dunng the fweAre T2n ths �l
be(ae March 37 0! each yenr Ne deducton is
sotght. ��,UN COU TY v DI��9Y{'�1' Recorder
See reverse siOe for ado'iWnal insVUCtbns errd qualificateons.
I Aoob¢anl fowner armntrdrl hwxr- see msf�ns on reverse sidel ..
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1. amJ� yCdr
twmber l legal desaipfim Recqd mlm
�-1 -ld - 03-000� 3 3/-0 �8 DO
ge/ Conbau Webtednas unpaid as d Mortgage I Cantrea iridebtedness unOaiC as af
Ma 1. airterrt year Cate of aDP��+
(� _3 . � i� o
tt no. what is his / her exact shara ot inteRSt9
tt rartie m remtl a QAfemnt Nan tlwt d app6rani, Indi
Nartre of nartgagee a mntraG u9er ^
AEtlress ot rtqrt9a9� or mnhaG seAer (n �
Name a1 assignee w othel wmu w halder of rt�ortgage
AOCren o/ assig�ea (numbar erM snee4 mY.
Y^'_ "'
N' CS 8�Itl11f OM11 D��/ If1211�/ WIIM
munty in Ind'ana? C
❑ Yes
Deduction apyoved In Cre amount of:
20 _ 20 _
sy�n� w c,�,b abn�
I/ we certiry undrl ihe nalry of per
owner / �ntracl buyer ot �he atwe t
�9^a91� wnersflAname) .
If owned wiN samew�e Wher ihan spouse.
cifl: smte, a�d ZIP code)
ard ZIP code)
'sTS l�9 �T�
If yes, what mumyl What Tabrg Diship'
COUNTYAUDROR
ezewstl Fa.rs af Atmn+er
20 � 24 � .
her Pege numbri
9 30�
��a��,�a�a
kgal a eduitade ovmM
❑ Yes ❑ No
�Is Ihe propertY in Ouestion: Mnue�y AssesseE
YJ'�� �OPenY � �!aM �
Has N'¢ tletluaion Exn re9uetted m proprny
fw arteru Y�! ❑ Yes ❑ No
�,��,���,� ���o...a.�o9
C:II'(� ���. .... �3�I
8 /03, �oW.p-p.......
a6ove and foregoing infortnalion is We and cortec[ a� Nat Me appfiranl L5 a resident ot I�qna a�w
�erty on date application is filed.
oam („cnm. ear. raen
Atldress of aWio�'vtd pefson (numbereM street �Y. sbte.
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Ll7(�70
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