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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship Year �
s FOR DEDUCTION FROM ASSESSED VALUATION � (�
� State Fwm 43709 (R11 I6-09) ��
� ' PresaibeC by DepatlmeM of Local Gwemment Fnarice
File Mark
INSTRUC770NS:
To be lled in person or by mai7 wiM the CountyAuditor or Counry Reaorder of the counry where fhe poperty is bcated.
Fdiny Dafes: 7) Real Pmperty: Must file during fha year for which the deductlon is sought. � Auditor
2J MobRe / Manulactured Hortres rrot assessed as Real Property Mus! file dunng �he fweNe (12) monfhs
betore March 3101 each year the deduction is sought. ❑ 42^ �
See reverse side foraddrtional insfrucGons arW qualifications. GIBSO
Appfrant r cr contrdp buyer- e 2�q s m mve�se sida) /_ ,
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M3�Ch 1, p+re�tl yPar
II rq, whal'a his / her exact share of interesY?
ge / Cantracl'u
Ma 1, wrrent ynar
If name an rem�tl a QflleRn� Nan that o( aOP�t'oWicate below.
Name ot mmpagee or mntraa sen rl
1
Address of mort�a9ee «mnbact se�er (number n
Name of assignee w other owner or hdder of rtprtgage
AdEfess of assignee (numDeraM stree; tlry. state, arM
Does appliont axn property in any oUer
counryinlnd'ana? ❑ Ye5 ❑ No
OeEUC�m appmveG in the amount oE
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Signature N Counry Auditor
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tlate o� aw�Leetia
If owned
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NRiat Tarirg �
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� Page number
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Is Ihe ap t Ne sok
legal or epuitable axneN
❑ Yes ❑ No
spouse, IMimte with whom
�e properry in Qurstion: Mnually Assessed
Real RoPeRY ❑ ?1Q1!�y �
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Dra���erN�•......•• 3.
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I/ We ceNfy under �he penalry of perjury Uiat Ne aDOVe and foregoing infortnation is true and cortect arid that the applirant is a resident of IrWiana and
awner I mntraU b�,mentioned property on date apPlicalion is filed.
sfate,
Paner af Attorney ar by IC 61.
Address o( authwvsd person (numberaM stree; dry, state,
�..�.LG'7 a �
Date (momh, Eay,