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T^'n STATEMENT OF MORTGAGE OR CONTRACT J�� � DN� oun 7ownship Year
_ FOR DEDUCTION FROM ASSESSED VALUA7�ON
• State Fwm 43709 (R71 / 6-09)
�' „„ PresQibed by Depanment ol Lo�al Goremment Fiw¢e
iNSrRUCnoNS:
O C T 2 2 2 0 1 Z Fi le Ma r k
To be fiied in person w by mail with the CowtyAudifor or Counry Recorder o( fhe county-wtiei@�the� -perty �s bcated. F� �� ��
Fifig Dates: 1) Real P�opeRy: Must file durirg the year Por which the deduction is soughl. g� \�iv\�I v��-\p� Coun Auditor
2) Mo6Ae/ManufaduredHanesnotassessedasR�ea�Property:Gl SON COUNTY AUDITOR��S ❑ CountyRecorder
6e(ore Ma�ch 31 0( each year tAe deduclion is
See reverse side 7or addiCana/ instrucGOns end qualfications.
npp5�ant (owner u ow�apo buyer- see re.wirlons m reverse sida)
� Key rvanCer / legal dzsaiption
a�-�9�31 -303 o0o ao
Y rnal popMy as d Mor(qage / Contract mdebtedness unpaitl az U
ymr MarM 1. a�rtent yew
�r name m�ema �s amuent man mat ot appurant
Name or «m,o-an sene.
�m Qn_a.c �
Address of nwrtgagex or mnbaa seDer (numbar ar
Name of assignee or oMer ovmer w twlder of mM�
AEdress of assiqnce (n�mber arM street arY. sfe(e.
u�dirate bebw:
rity, stefe, aM LP cade)
Dces a�i�nt own paperty in any olha If yes. whal munt7/t
cwntymind'vna? ❑ Y¢S ❑ No
�
De�uaon ved'o� Me artaunt oE ' . i'
20 20 20 20
unpaid as d Is Ne appGrant Ne sde
legal w equitaNe rnmell
❑ Yes ❑ No
wiM someorre dher tlw� spouse. uWirate WM wlwm
the pmperty in QuesCOn: MnuaDy AsSessed
}}t�i Pro� p nm,�ny w�a
._X-- �� ^
f
ia-s�►�
Fz��
�unsted an P�Y
❑ Yes ❑ No
zo zo
oa�e tna�vn, aar. r��
I/ We certify under the penalty of perjury that the above and foregoing infortnation is true and cortect and that Ne applinnt is a resident ot Indiana a�
owner I mn4act buyer of the aforementioned property on date application is filed.
Sqina•,ure (ownrlS fiID �me) Date (rrontli. deY. Yae+)
5xet dN, �ta,
bylC
Address of auNor'¢ed perscn (numberarM sbee; cily, state,
Date (rtron(h. tlaY. yea�
/o.�.a -
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