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T"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
FOR DEDUCTION FROM ASSESSED VALUATION
• Sfata Fwm 43709 (R77 / 6-09)
S,� 1 prewibe0 by DepartmeM of Local Gm�emment France
INSiRUCT10NS:
To 6e filed in person w by mail witA �he CounryAUditof or Counry Recorder of the county whe2 the property is located.
Filiig Dates: i) Real Property: Must fi!e during the year (or which fhe deduclion is soughf.
2) Mo6de /Manufactured Homes rrot assessed as Real Pmperty: Must file dunrg Me twelve (12J months
befoie Mam,h 31 of each year Ne deduction is sought.
See reverse side for addifional inshuctinns and qualifirafions. _
I( no. whal is h's I Mf exatl share Of Ntrlesl?
If name m remrtl is 6ftemnt tlan Nal of aPP��t'odit�ate 6ehv`
mortqagee or conttaU seqer �
!I.'�Td
cG}; sYd�.
Name �y oorer�9 er a naaer or mortgage
dw �[v : -3- /c�
Address of assignee (number eM strec4 �: state, aM ZIP cotle)
Does applitant ovm praperty in any oNer If yes, wlu
munry in Indana? r-� ._ r� ..
cEon approVeC in Cre amount aE
20 20
�. d -�.�-,
as W Mortgage / ConValY mCebtedne�
Eate of ep
� awntd win someone dher ihan spouse,
COUNTYAUDROR
20 20 20
SignaMe of Cowry Audiror Caunry
I/ We certify under the penalry of perjury that Ne above arW foregoing infortnalion is W e antl c
owner I contract buyer of the aforementioned property on date appiiratlon is filed.
/ SIBn w (owne/shAname)
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FWI ' n u andstree4 0. sbte, andLPcode)
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Pelson aullror¢ed Gy dWy exewte0 Power of Atlpney w by IC 67.1-t2-0.7
Mdress d auNwmed person (number arM sneel, dry, state, aM LP code) .
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Remrd numbel Page numbel
0/� 3�00
unpaid as of Is Ihe app�nt the soie
Iegai w ewirade ownM
� U6 ❑ Yes ❑ No
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