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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
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% FOR DEDUCTION FROM ASSESSED VALUATION
� Sfate Form 43709 (R71 / 6-09)
�' - � Presm"bed M DePartment af L.ocal Gwemment Firence
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i Ma
INSTRUCTIONS:
To be fiied in person w by mad with the CourrtyA�ditor or Counry Recorder o/ fhe county where the property is located.
Fi7irg Dates: 1) Real Property Must file dunng the year for which fha deduction is soughG Counry Aud"rtnr
2J Mob�7e / Manufactured Hortres rrot assessed as Real Pruperty: Must fi!e dunng the hvelve (12) months O���f'1_�der
before Mamh 31 of eacA year fhe deduction is sought L�� NJ<
See reverse side /o� addilional insWCfions and qualifications.
Appfxant (owrier or C buyer � see reslr'r�iwa rn rere+3p side)
Tawg Distrirl ' I Key
Acesed vahie d real pmperty as of
March 1. au�enl Yrar
If no. what Ls his / her erarl share of intrse
If name on remrd'a d�Remnt than that of a
Name of mortga9ee or contrarl seller
PAdress of mortga9e� ar mntract seDer (n
Name af azsignee w other owner or holde��,
Martgage / Contract inde6tednrss unpaid as af
Maftl� 1, arr9�V'74DYS _ '
sfree4 ��}: stale. ard LP code)
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c�aem N z=�='� �:s: �-_ � ���,_:_�._ "....,=—=,m,a osmua
����m�am
20 _
signame d Camb nuccw
Dra�r�ci� NO...°�Ola........
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Card NO. ..... . . ........
�8��141•b1
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t Remrd numbrl
b l
: UWe6te0ness unpaid as d I
I
than SP�. indkate with who
v� u No
Is the ProP�Y in Questim AnnuaM Assesed
❑ Rea� aropeny ❑ amua�ynssessed
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Has Nis dedudion Eeen re9uested m D�Y
fmaurentYraY.+ � Yes ❑ N
zo 20 _
Date (rnaMh, day, yea�
I I We certify urWer the penatty o( pe�ury that the above arW foregoing intortnatlon is We end corteC arid that the applirant is a resident of Indfana aM
owner I contract 6uyer of the afwementimed pmperry on date application is filed.
natlire lovme/s hdlWrYel �. i i Dale (nnntli. daY. Y��
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of auNOraed person (number aM snee4 mY. �te, aM LP cade)
Date (monfh, day,