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"�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship Year
, FOR DEDUCTION FROM ASSESSED VALUATION
$tate Fortn 43709 (R71 / 609) � �
�` � Presrnbed Ey DepartmeN of Local Govemrtrent Fuance
"'� g 'FtfE�
wsrRUCnoNS:
To 6e fiied in person or by mail wiN Ne CounlyAuditw or Counry Recorder of the counry where the property is locat� T
Fdirg Dates: 1) Real Property Must fJe dunng the }rear for which the deducfion is sought.
2J Mo6�7e / ManuFaclured Homes irot assessed as Real Properry: Must file dunng the tweA2 (12J rtwnUu �
betore Ma�ch 31 o)each year the deduction is saqht.
See reverse side for additional insVUCUons arM qualifications.
AuofFB�� (owneror coritrart buyer- sre reSnrAOns m reeersa side)_ .._ •..•••• .
Asesse0 value dreal popemj az W
Ma�d� 7, ar�erd year
tt no. what 5 ha / her exaf3 share af interesi?
If na11�C ai �¢CNd a
rtvxtgagee m m�bact seller
contraU se0er
-19- �l- �J0.69
r/ Contract inde6tetlness unpaN as of N
artem year d�,
stree4 ury, sb+e, aM ZIP code)
Name of assignee w ofhr! ovmer or hdder of morigage
AGtl ot assig (number aM stree4 GN, slate, anc
T r%(.�J I .
Oces appli`snt ovm ryoperty in any oNer
counbinlMiana? ❑ Yes
❑ No
Deductlon appoved In ihe amount of.
2� _ 2� _
Signahne W Ca�mbAiWitor _�
O ,57
I( yes, what munD/7
�o�
zo �
- o �- 6 a-
�e / Convact Inde6te0ness unpai0 as d I:
epp&ation k
roo voo
ieorre aher Ihan spouse. indimte WM wtan
County Audilw
Couny Remrder
Page number
ves u No
IS tlu DroOertY in que5tion: MnuallY ASS
❑ Real ProPertY Q Mnualy Asse
Mob�e Fiorne
D'atricl? Has Viia AeOUGim Oeen re9uesteE m P�P�Y
— — .__ ._�.�..n - ____ .__�-."_
= m�y�x, � �t-mY 5
— rnE�.sssA C -
- �a- yo�7 -
I/ We certify under the pen� of perjury e above and foregning infortnation is W e and wrreU arM that Me applirant is a resident of IrMiana aM
own / contract buyer of the afaemen' properry on date applicalion is filed.
�/ Si9na (ownerY hN na Date (rtanth. daY. Yoe�)
/�
2si0ent ad W appGrant (numDe sheet, tiry, state, anA LP mtle) �
03 ' u S f F+ 7/a�/S�
Peison auNaaed by Eidy ezewtetl Power M Y or by IC 67.7-t2-0.7 Dete (monfh. daY Y��
Pdtlress ot auNwaeE person (number aM sbee4 ciN. state, and LP code) .
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