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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ .• FOR DEDUCTION FROM ASSESSED VALUATION� ��
�• Sfate Fortn 93709 (R71 / 6-09) ��
�` � Prescribed Ey Department of LoW Govemment Frunce
� File Mark
INSTRUCTIONS:
�r1��' Fortn fde0 wit�
To be filed in person oi by mail wifh the CountyA�ditor or Counry Recnrder o/ the coun0 �ert�the �rry is located. /
Filirg Dates: 7) Real PropeRy: Must file durng the year /w which the deduction is sought. �Q✓ Counry Fwdimr
2) Mo6Be / ManuFactumd Homes rrot assessed as Real Property Must fil� dmir�q,(�lwe. __ Ng (72) months
before March 31 of each year the deduction is sought. �� (��T ❑ Counry Recorder
Seereverse,sidelqr!pddiUOna/insfrucdonsarMqualifications. �,�„�„��„_,v,,,,,,,,,,
r ' stri ��1 IKeY�w
�������a�
Mard� 1, aarrnt year
11 ro. wha� is his l lrer e� share o( intrJesl?
If rame m iecad is dn[urnt Nan that o( aDp[
IJame of mottgagee w contrart seller
!�-£X� nl��-t�a7 I.__._.._..
4Mehtedness unpaid as of Mortgage / Conbaa i�Webiedness unpaid as M
v � ^ �1 tlate of apptitation
mntrad se0er (num6er and street, crty. state. ard LP code)
Name of assignee w o�u ownet or hdder of mMgage
Address o( assgnee (number and stree4 �Y. sbte,
Does ep0�i�2nt ovm property
counyinlMiana? r
20
Si9�aMe
It ovmed with someo�re dher Nan sG�e. indicate with
DCa1\'CI' ��.. ��I�.......
fc:��-� �o. .. 5.�3�.......� _
mmearr�,�cor. 11�,��'.o\ .
C.0
—�� tu � 20 � 20
I/ We certify under ihe penalry of perjury that
owner I contracl buyer of Ne aforemerrtioned
17
��+
and fo
n date
ah< s+a�rt �, P
r�
, ar ny ic �i.i-is-0.�
sveec �: uate,
Counry
Page number
Yes LI No
Is tM P�Gert1' N Oues9m: MnuaOy Kr�Kr.:esse0
❑ Rea� a'oaeM ❑ /+�N�
Moale Hortie (IC 61.
Nas this deducfion Eeen reQUesteO on prope+ty
for a�rem Y�R ❑ Yes ❑
�
Date (month. CeY.
20
imiaGOn is We and cortect arM Uat che appiinnt is a resident ot Indiana aM
is mea.
�� (�,o�m, aar. ree�
r�d