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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
� FOR DEDUCTION FROM ASSESSED VALUATION
• Stale Form 43709 (R71/6�09)
4• � Presaibed by Departrtrent af L�I GovemmeM Firance
�lSTRUCTIONS:
To be filed in person or by mail with the CounryAuditor or Counry Remrder ol the county where the property is loca . �
Filirg Dates: 7) Real Property: Must file durirg the year Por which the deduction is soughf.
2J Mobile /Manufectured Homes not assessed as Real Prdperty Must file dunng fhe tweNe (72J months �
before March 31 of each year the deduction rs sought.
See �eversa side (or addifional instrucUons and qualfications. C.
qppfu�ant (mmer a buyar- see resln ' m reverse side) � 1 1
1:�.nTi
tl no, what k his! Mr e>aa sha�e ot intemsE?
tt �ame m remN is dite2nt lhan Iha� al appOmn, trdi�ate Eebvr
7 C'onu'n'ryAUditor
681k4y Recordu
-,�v - uv � i v.c a i
aG intlebte�fress unpaiE as d' Mortgage I CantraU "uNeMedness unpaid as of Is Ne aDP�nt the sde
year date o1 ePP�� k9al or eWilade ownell
❑ Yes ❑ No
If awned vrith someane oNU tlun spouse. mdcate wflh wMm
IS SFIC P�P�Y Ifl CIICSLCII: Mf1U2�Y A552S524
❑ Real Property ❑ ArmuallyASSessed - - -
Name or nwrtgagea w mntraa seuer // , /
� jc�•nGNW
ACdr� of rtartgagce w contract seller (number aM stree4 �: stale.
Name ol assignee or oNer owner or haider of mortgage
Ad�2ss of asagnee (numDer arM stree; tlry, slafe, aM ZIP cotle)
Dces appii�ant wm yopeM1y in any oNer If yas, what m
munryinlntlia�? I"I ..__ I—i .�_
[dillg��I_Pl�]iLli
amount of.
Has this detludim Oeen 20uestetl m prapnity
fw a�rent yeaR � Yes ❑ No
20 _ 20 _ 20 20 _ 20 ZO _ 20 _
sy�awre d camb nwnw caruy oate (mo,w,. aav rea�
I/ We certify untler Ne penalry of perjury that Ne above arW foregoing infortnaGOn is We and cortect arM that Ne applinnt is a resident of IrWiana a�
owner I ntraG buyer of the a mentimed property on date application is filed.
�^�R ( 74��i I� name) A x Date (month; day, yea�^
Persd� auUwrrzed by EWy ezecuted Power af Attaney or by IC 61.7-12-0.7 I Date (mon�h, d2Y N��
Add2ss W auGror'¢ed person (numberaM streef, fi(y, stafe, and LP code) .