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"'�q STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun�
a FOR DEDUCTION FROM ASSESSED VALUATION
n State Fomi 43709 (R71 / 6-09)
�` f Presoibed by Oepanrtrent of Local Govemmenl Firiance
INSTRUCT70NS:
To be filed in person w by mail wifh tAe CquntyAudifor or Counry Recorder of the county where the pioperty is located.
Fifrrg Dates: 1) Real Pioperty: Must file durirg the yrear /or which the deduction is mught.
2) Mobde / Manufactured Homes rrot assessed as Real Pruperty: Must fife dunng fhe fweHe (12) months
6etore March 31 0! each year the deduclion rs sought.
See reverse side (or d�ditiunal instructrons eM qualfications.
Appkant (ownerar �ra b�er- see�re�N'ctio�s m rererse3C�e) %i � _ _ . �
If no, what "s h'a / her e�ct share of intercst?
I( narne m remrd "a Nfterent Nan thal o( aDpOCant, mEifata Debw.
Name at rtartgagee or mntraG
contracluAer
assignee w other owner or hdder ot mortgage
ciN, smte.
AECress of assi9nee (number arrd stree4 �: sfafe, and Z/P crotle)
Dces applinnt ovm property in any oNer If yes, what
munry in IMiaria? �.. �..
Eate
t� 9COyfllHAuditor
WI[
,3 ❑ County Recorder
(
ISON CQUa7Y
AUDITp
Recortliw er P����
unpaid as d Is Itre aPP�t Ne sde
legal w equitade avnel7
❑ Yes ❑ No
tl awned wi� someone other tl�an spouse. udimte wflh whom
Is ihe D�VP+�Y in puestion: MnuaOyASSesseO
❑ Real Property ❑ Armuaily Assessed
:ted m DropenY
Yes ❑ Na
COUNTYAUDROR `
Deduction app�oved'c� Ihe amount of:
20 20 20 20 _ 20 ZO _ 20 _
Sig�anne N Co�mN Aueitw CouNY Date (rtpnfh. daY• Y��
I/ certi the penalry of pe " ry that the aEOVe anA foregoing infortnalion is we and mrtea arM Nat the applicant is a resident of Indiana ard
e� con e afore tioned property on date application is filed.
vme me) Date (montlt. daY. YgeA
FW 'dent appf�nt(num ran7 440;���e,anCZiPmde)' �
authoraM Ey EWy exeryted Power of Attorney ar by IC 67.1-12-0.7 . �(�. �Y. Y��
Pddress of autha'¢ed person (numberaiM sbee4 �y. stale, antl LP code) .