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�
ry� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
= FOR DEDUCTION FROM ASSESSED VALUATION
� State Fortn 43709 (R71 / 699)
�'` ✓ Preun"betl by Depariment of Lnd Govemment Firwrc
� File Mark
INSTRUCTIONS:
To 6e filed in person or 6y mail wifh fhe CowryAuditof or Counry Recade� of the counry where the properry is bcated. F� ���
FNrg Dates: 1) Real Property Must file dunrg the year fo� which the deductlon is soughG � County Auditor
2) MobBe /ManuFactured Homes not assessed es Real Property: Must ne dunng the hvelve (12J monfhs
6efore March 31 of each year the deduction is xwght. ❑ Counry Recorder
See reverse side /or adddional instructions and qualifications.
MatUi 1. a�lt 1r�r /
C�
If ta. what Is his / Icer eraG
tcey ruunca � lega� a rim
�v - -�°"/ -
Mor(yage / Contract im
MarU 1. wrtent yrar
than Nat of app6rant, Ndkate Eebw:
Name of rtnrtgagea or contrarl setler� _///J(/C.L� /�• /
6
Y� C�
Pddress of morcgagee a contraq se�el (n and cdy, sfate, ard i
Name of assi�ee w atl� oxmer w holder of rtqrtgage
Ailtlrnss ot assignee (number arM stree4 ml: ��, aM ZIP cotle)
Dces apd�nc own propeny in any oUer R yes. what muntyt
munry in Indena? ❑ Yes
❑ No
f.:.IT.�^I
= OUO. ���_
inpaid az U MMgage I G
WhaI7
za_ �_ �_ 20_
Sig�ahrte N Camty Autlitor Counry
I/ We certi(y under the penalry of perjury that Ne above and (o2going intortnaGOn is
owner / mntracl buyer of the aforementioned property on date apP�ication is filed.
Person authmaeC Dy Euy execu:ed Power af Attomey or Dy IC
AOEress af auNa'¢e0 person (number arM sbeeG ury. sbfe, a
0
. ��•T.-]
htNness unPaid as of Is Ihe ePPriont Ne wk
legal a eQUitaNe wmrYl
❑ Yes ❑ No
spouse, 4Micate wim rfiwn
Is Ihe woG�Y in OuesSOn: MnuaOyASStsseO
�Real RoPeKY ❑ ?���Y � . . .
a� � � _
�3��
�11n1
-i�,�-iL
i
No
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