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^'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Co 7o p vear
_ s FOR DEDUCTION FROM ASSESSED VALUATION
� State Fortn 43709 (R71 / 6-09)
�' % Pr¢saibetl by �epartmenl of Local GovemrtreM Fnance
��µ File Mark
JSTRUC710NS: C ^ ^^ '�'—
b 6e filed in person or by mail wrfh fhe CountyAuditor or Counry Recorder of the county where the pioperty is bcated. F� ��
Fifing Dates: 7) Real Pmpe/1y Must file durirg the year /or vrhich the deduction is wughf. ��Co�uC�r:p��A¢or
2J Mo6de / Manufactured Homes rrot assessed as Real Property Must file dunng fhe fweNe (12) mon�SO ��TY HU ut i Utc
betore March 37 0/ eacA year the deducfion is sought. ❑ Counry Recorder
See reverse side for additiona/ inswcfnons and qualifications.
nimber
A�ssed raqre U 2al P�Y as d
Ma�r�h 1, alfent yeer
It no, xfiat fs h's I her ezaG share of inten
If name on �emd 6 Ei(terent Can Nat o1 �
Nam rtnrtgapea� seQer
/ i✓/ / /�.,w��.
Address of mort9a9ce w mntrad se0er G
Name af azsignee w oNer o�mer or hddi
ACtlmss ot assi9nee (number aM sfree4
Dces aPpfimnt own property in any oNu
munty in InOiaria? ❑ Yes
.
Detluction appmved in ihe amount oE
Ser aM sfree; ury, state. and LP code)
mortgage
state, aM Z/P cotle)
If
ves. wns� mumy± v
I No
20 _ � 20 _ � 2b
Ca�mry Auditor
20
someore otner Inan spouse.
RecoN numbel
legal or equ0ade bwne!?
❑ Yes ❑ No
whom
Is tlie P�G�nY in Guestim: M(wa0y Assesse0
❑ Real RoPeM � !?�^�!�h! �
Dl"aiti er Np,.
C7Y�f 1\`O .���... ..
���
R �3,t�j'� �••.........
_�
20 _ � 20 _
Date (monM.OaY, l��
P�nY
20
No
I I We certify under the penalry of perjury Ihat Ihe above arW foregning infortnalio� is We and cortecl and ihat the appliranl is a resident of Indiana arM
owner I mntract buyer of the atwementioned property on date appiicabon is filed.
��e (owrieh hNrom� n. Date (monfh. daY.Yge+)
t eEdress W appfi�ant (nuMGeranC stree4 �1; �te. end LP ar
� 8 s- ►-a�,t� P�'.nce�-un �-4-v
roraed by dWy ezeartetl Power ol Attdney or by IC 61.1-12-0.7
person (numbereM sbee4 u�; sbta, end LP mtle)