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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun'
• FOR DEDUCTION FROM ASSESSED VALUATION
• Stata Fwm 43709 (R11 / 6-09)
� % PresoiDetl by �epartme(n af Lnd Govertvnent France
INSTRUCT70NS:
b 6e filed in person w by mad wRh fhe Co�ntyAuditw or County Recorder of the county where the property is bcated.
Fi7ing Dates: 7) Real Properly: Mus[ file dufig the year (or which the deduction is sought.
2) Mobde /Manufactured Homes rrot essessed as Real Property: Must file dunng the fwefve (12) monfhs
betore March 31 01 each year the deduclion is sought.
See 2verse side foradditiunal instructions errd qualifications. G�
Aa�sseE vdh�e d tral propgly az ot
Ma�d� 1, axmrt yPar
u ro. wha� is nis � he. ez� �a�e o,
If na�rie on remtl 5 Qfiere(11 Uian tt
Name af mwtga9ee ar mntrffi seller
AddBSS of nprcgagee w contract se0er
Name of assignee w oMer owner or hd
ACtlress ot asti�nee (number aM stree
Does e�i�ant ovm property in any oW
counry in Ind'ana? r-� ..
20
apryoved in the amount ot
rtprtgage
— � VVV. -
r/ Contrac[ inde6tedn�s unpaid as of Martg:
arteM year tlate o
aMZlPcade)
0 0� � o aD�
mtyt NRat Tarirg Districl?
COUNTYAUDROR
20 _ � 20 � 20 _
20 _
y�anue U Camb Auditw I Caunry
I I We cerOfy under the penalry of perjury that Ihe a6ove and fo2gang intomiation is true and m�
owner I wntract buyer of the aforementirned property on date applicauon is filed.
0
ull reSlOent eEdress ot appfmant (numDer and stree4 �Y, stat aM ZIP m
� S° 5 d l�.,i N,ll ;�J ✓ "nc.�
Persm autha¢eO Dy duy esecuteC Power of Attamey m Cy IC G7.1-12-0.7
Add� ot auVior'¢ed person (num6er arM sfreet, ary, s7ate arM LP ootle)
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Year
�,�c?+ud'rto�
,F.aunty Recwder
num0er Page number
fs of Is ihe app0�ant Ne sc
legal w equitade owr
Y� u r+o
sP�'e. hWicate wM w�orn
rIs-t,h,Le property m Question: MnuzM Asessed
�yneelRoPertY ❑�°�Y�
%� Moble Hm�e (IC 6
Has Nis EeNMnn Em� 2QUested m 7�Y
���� ❑ Yes ❑ I
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Date (monfh. daY. Y��
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