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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun `
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• FOR DEDUCTION FROM ASSESSED VALUATION
- Slate Fwm 43709 (R71 / 6-09)
4' �w ° Prrsrnbed M DeP�N at Laal GavemrtreN Fitance
File t� 2 9
INSTRUCT70NS:
To be lled in persan or by mail with the CowryAWitor or Counry Recorder of the county where the pmperty is located. F� �� "'�'
Fi7mg Dates: 1) Real Pmperty Must file dunng Ne year for which the deduclion is sought. �C �C�o'unry A r
2) Mo6r7e /Manufadured Homes rrot assessed as Real Property: Must fi7e dunng the hveHe (72) months n Co ty
before March 31 o/each yearthe deduction is sought. GI�$'�N cOUNTY qUDI
See reverse side for adtlitional instrucGons and qual�cations.
Detlucfian approved 4� tlre arrount of:
20 _
Sigrahne N Go�mb Auditor
20 _ � 20 _
COUNTYAUDROR
DI'�1Yer lY�..�1,J.�R�.......
20_ � 2(1_
I/ We certify under ihe penalry of perjury that the abovE C a r d I�' O. .. ..�� ��. ... .. applirant is a resident of Ind'dqna aM
owner I contracl buyer of the ato2mentioned pmperty [
,�o �,�,�� � _� , �3o,a�o.�= ��,,�.daY��
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Pddress of autha'ved pem.on (numberantl sneet dry, sbte, en0
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Date (monfh. daY.
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