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Nna STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ovmship ar
• FOR DEDUCTION FROM ASSESSED VALUATION
• Sfate Fwm 43709 (R71 / 6-09)
S � Preunbed M DePa�eM of Loral GovemmeM Fuiame
File Mark ,
INSTRUCTIONS:
F . -
To be filed in person w by mai7 with the CounryAuditor or Counry Recader o/ the counry where the pmperty is located. ��
Fr7mg Da[es: 1) Real PropertY. Must file durirg the year lor which Ne deductlon is soughL �. Ror
2J Mobile / Manufactured Homes not assessed es Real Property: Must file dunng the hveNe (12J months � .❑
before Mamh 31 01 each year Me Aeduclion is so�yht Coun R er
See (everse side lor addiLOnal instrucMOns and qualifications. G I
A� rdhre d real propelty as of
MaN� 1, amerd yPar
rc`w. what ts h'a / her e�ct share o�
rc name a, reoora is dmmunnt u�an u
ryame a} Rprtgagee or conUaU setler
qC�l f mortgagee w contract sWer
Name of assi�ee or othel owner or hd
manherlle9aldes
/ _I.'>�
'�� � ' �
lebtedness unpaM az
cant'oWVate 6eiovi:
�er erd stree; uy, state, aM LP
morigage
�ab, and LP code)
linnt own pmperty in any other I If yes. what munt�/1 I What Tadng �a4icl7
���� f�'�^ ❑ No
De�ucGOn appmved in �he
Record numbu
w
❑ No
SpO1SC.01d .k2tC WI�11 WhOffl
pelty in 9���: �Y �
ProPertY ❑;�ii!uiallY'Sssessed . . .
- - — J_
� �� /�� � � � )
��Uc.iEi �:{1f.+.-/�.� f'�C.c.C.T'
Ly,�,� �✓
/CT V O /
20 _ 20 2p 20 _ 20 _ 20 _
Sigrenue m Cnmb nwitcr counry oate (rt�oNh. aar. �ea�
I I We certify under Ne penalty of perjury that the above aM foregoing infortnation is true and corteU arid that the applirant is a resident of IrMiana ard
owner I�ntrad buyer of the aJ�oremenUoned property on date application is filed.
s�anaai� hiDfia Date (morNx daY. Y�
it aCdress of appRnnt (numDe� aritl sbeet, dty, state, arM )
I S. lvKr` r G .L�-S` J4 L C� , •� - �lo G O
mfaeE Ey dWy rn cetl Power o(AtmmeY w by IC G7.7-72-0.7 Date (monfi. daY. N
aWro�'vetl per'..on (number arM sbeet, fity, sfate, a+M LP mde) .
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