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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun ship
FOR DEDUCTION FROM ASSESSED VALUATION
: . � �. ' State Fortn 43709 (R71 / 6-09)
�,,,, Presaibed Ey DePM�nt of Local Govemmenl Frwca
wsraucnoNS: ����`2 2012
Fortn Ne0 wiN:
To be filed in person or by mail with the CountyAUdito� or Counry Recorder o( Me oounry where the property is focated. C.�, N�,,;z3C F�
Filing Dates: i) Real Property: Must file dunng fhe yrear /or which the deduction is sought. � ����
2J Mo6i/e / Manufactured Homes not assessed es Real Property: Must file dunng the hveNe (12) monfhs n
be(oreMarch3lofeachyearthededuUionissought. GI SOM1iO��F �, Fj
See reverse side lor additbnal inshuctions arM qualifications.
nppf�nt (owre�,wcontraa 6uyr.{ sea re�s m rcveaas �ide). ' _ _ n
AaesseC vah�e d real P�O�Y as of
M911�1 i. flYlfll� JR9f
u no, what s ns r ne� �ae shate m�vmst?
u nan,e on 2�a B 61re�a,1 a�ao u,a� m acpB
Name at rtnrt�ee ar mntracc seAer
� l � l ' 'l'C.JL)U -
Mortgage / Convact inde6tetlrress unpaid a U
M2f�j1 i.P�rre..�..��.
S�St,�SD
(nem�6uendsvae; ciy, sbte. aMLPcode)
Nher owner w MNei of rtqrigage
J Remfd num�v
� � ^ `i eZ � �
MM9a9e I ConttaC inEebtedness unpaitl as af Is ihe
Eete of appGCelbn legal i
.. �vmed witli mme�ne other U�an spouse.
Mdresso(assign� /�n, C /� "'
• � LLCC.J/ AJ��J�
Oces epplifant a .r,S � hat Tadrg Datria7
m�,uy �� i�c� A/U L� ��!� /e.
��_CO77 4UDROR
C�j \./
DeductionaGP� VQ ��c?J
20 I 20
�9��
Coimry
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Page number
avmell
❑ No
�e pioperty in Question: MnuaM A�sesseE
Reel PfoPeRY ❑ M^!dl�'.A�sed
Has Nis tledwSOn
for airtent yeaR
�
m pmperty
❑ No
r�
I/ We cerdy uMer the penaliy of periury that the above aM foregoing infortnalion is true and correct and that Ne applipnt is a resident of IrWiana arM
owner I contract buyer of the afaemerttioned D�Perty on date application is filed.
i`a`�wne/slu0nartre Date (nwth. daY.Y��
C.� 1' s��i _ � /
mY
Oy Eidy exeaRed Parer W Avomey or by
erb n �oee)
a.v.�� v.'�
AEEress of auNOraed person (numEerantl.weeG �y. state, arM LP cade)
y
o� ��,rn, eer.
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