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Nn STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship vear
__ . FOR DEDUCTION FROM ASSESSED VALUATION
� . � Sfate Fam C3709 (R77 / bO9)
�` �,� Presmbed by DeD�M of Local Govemment Franca
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INSTRUCTIONS: p�p
To be filed in person w by mail wilfi Me CountyAuditor or Coun Recorder of ihe coun wheie the io F�,L j, 2� � 2
�Y h P PQM is located.
Filirg Dates: 7J Real Property: Must file dunng the year tor which the deductlon is sought Counry Aud'rtor
2) MobAe / Manufactu2d Hortres nof assessed as Real Property. Must fife dunng Ne (weNe (72) monfhs C � y�,-�--
6e/ore March 31 0/ each year Ne deduclion is sought. Q C6�Y��de�
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See reverse side /or additional insfruUbns erM quelifications. (: i a cn.� r., ��.._.. .. v
Tasir�g �� / - Kty nm�ba, �ge� d�Gron � Remb mmEe.
� - i�_ _ �04_000, oa8-oa� i;�.
As¢sed vaqc d2al VoG�Y es d Motyape / CantraY Inde6teE�msS unpaid a d Mortgape / Contra�Y indeD4Wr� �m7aid as d I
Ma�fh 7. qam¢ year Merd� i, artent yeer date oi app�ptiWi I
Qn nvZ�
It no. what is his / her eracl share
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AddRSS of rtnrtgagee a[�tract se0er (num6ar eM stree; city, sfate, aM LP code)
Name of assignee w oNer owner or halder ot morigage
�d� o� �,� (numDer aMlWee; raY, state, entl LP cade) a� 3 A
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Dces appl&ant wm pmperty in any dhn It yes. what munt�R What Ta
munryinlndiana? ❑ Yes ❑ No
DeaucCOn approved'e� tlre amwnl oE
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�a dcrnmrya,anor
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I/ We certify under Ne pen ot perjury
owner I contrad buyer of the aforemerrtic
Person
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maWe oxireR
Yes ❑ No
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above antl toregoing infortnation is we and correa and that the applipnt is a resident of Irdiana and
�erty on date applicatlon is 51ed.
person (numberand sheet, ciy, state, anE LP code)
Date (monfh, tlay,
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