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Q�
STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship Year
_ : FOR DEDUCTION FROM ASSESSED VALUATION
� State Fortn 43709 (R71 / 609)
�` f Prescibed by Departmenl ol Lnml Govemrtrenl Frtaxe
� Fil
lNSTRUCTIONS:
b 6e fried in (� F� �� ��
person w 6y mail witfi (he CountyAuditor or Counry Remrder o� the county whe�e the property is bcated. (�'
Fitirg Dafes: 7) Real PropeRy: Must file dunig fhe year /or which the deduction is soughL J P� Zp���y p,�ditor
2) Mobde / Manufactured Homes rrot assessed as Real Property Must file dunng fhe tweHe (12) months C' . unry Recordu
befora March 37 of each year the deduction is sought.
See reverse side /a addifional insVUCUons and qualifirations_ V
Auo&ant(owneroraonhaUbuver-seereSLirb'onsmrerersetidel n � TY A�iniTnc
GRi�°�
.�u�ll
I( rq. what ts h'a! her ezaG shaR of
If narne on �eoortl a 6Remnt Uan
Name ot mongapee « mntract s§
er /�Egal GesaiPtian Retord number Page number
-�oo - ool. 0 3 9-o a/ �.D / a- o� S
Mpr(p�ge/ Contraci intleb[e0�rress unpeid az of Abngage / Cmvxt iMebtedneu unpaid as o( Is the eppf�nt the sde
Mard� 1. wrtenl `Re� date of aP �ega� ar epuilade ownell
❑ Yes ❑ No
If ovmed wi someorie other ihan spouu. udwste WN whom
+l'uMicate bebw: Is iM DroOenY in Ouestim: MnuaDy Acessetl
❑ Real RopeNy ❑ Mnually nsswsed
MoWle Fiort�e QC 61.1=
Address of nwrtga9ee «cantract uller (numbe� and s0'ee4 ciN. s+ete, a.
Name of assi�nee w otlrer awner or holder of mortgage
Address of assign (number aM sveet, dry, slate, aM Z/P ootle)
A s 3c�-a-
Dces appfirent ovm pmperty in any aher If y�s, wha[ mu�
munry in InCiana? ❑ Y¢S
❑ No
Deduction apprwed'ui ihe amount oE
p- � �-
I I We cert'rfy under the penalry oi
owner I mntracl buver of Ne afor
Oy duty executetl Power
7e�
20
/.o � L
v�rtw� r�oq o�v�n?
COUNTYAUDITOR -
20 _
Counry
2�
ihe a6o nd foregoing infortnation is We an
pmperty n date appliption is filed.
state, and ZIP mtle)
ney or Cy IC G7.142-0.7
ciy, state. and ZIP code)
Has Niv dedudion Oeen re9uestetl m 7�Y
for quRrt yeaR �
❑ Yes
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. � Data (mo9m. aaY. yqar)
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