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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ovmship vear
_ : FOR DEDUCTION FROM ASSESSED VALUATION
� SHte Fwm 43709 (R71 / 609)
�' � Prescibetl by Departrtrerd o1 Lowl Govemment Fuurxe
� File Mark
INSTRUCTIONS:
To be filed in person or by mail with fhe CounryAUditor or Counry Recorder o( the county where the properry is located. F� �� ��
Fitirg Dates: 1) Real Property: Must file durirg the year (o� which the deduclion is sought. � Counry Auditor
2) Mo6i/e / Manufactured Homes rrot assessed as Real Property: Must fi/e dunng the hveNe (12) months
6efore Maich 31 of each year the deduciion is soughf. ❑ Counry Remrder
See reverse side 70� addilional instnrclions arM qualifications. �
MG��t(owneror 6uyer-seere�mr�e esitle) A
.,�e
��! =� � Q.`i��1�
� . :.� • I�
If ro, xfiet I5 his / hu eraf2 share of interest?
tt narne m reootd is dMerent tlan Nat ot applicanl mdk
Name ot nkvtqagee or contrarl se�er
AdEress of m�utgagee ar wntract se➢er (nun6er eM sb
Name of assignee w ofher wmer or hdder of morigage
beb�r
�; ��.
AdAre55 0l assignee (num6er aM streel, dly, slete, eid ZIP cotle)
Does epdibnt own property in any oNer I IF yes. wha!
taunry m IM'ena? n., f'l ..
�
tltade awnM
Yes ❑ No
If ovmed with mmeone other Ihan spouse, iridicate wtth whom
Is Cre pfopeny in 9uesoon: Mnua%ASSessed
❑ Real ProPe�Y � ?!?�!�N �
NTa� Ta�dnj Dabid7 � Mas IhK �+eduction been 29urstetl on 7roP�Y
r��' r� .. r� .
duction appro+ed'v� tlie amount oF. V � � � • • • • • •
v�`I��CC\0... •
20 _ zo _ 20 �� `f . . • • ' ' _ zo
panne W CounN AuAitor C:l l�\I On' .••••' (month. daY• Y��
�W(�� � I_..m
I I We certify under the penaliy of perjury tnat the above and (ore .. ��urma6on is W e and correct and tha[ ihe applinnt is a resident oF Indiana and
owner I mntract buyer of the afaementimed pmperry on date applicabon is filed.
�`anire (owner's7W reme) . /1 Date (monfi. daY. Yea�
Dy Ouy executed
state,
Cy IC G7.14
AdOress of authoraed person (numberarW stree; dry, stale, and ZIP tode)
Datc (monfh. daY. Y��
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