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"�� STATEMENT OF MORTGAGE OR CONTRACT INDEB�BD� � C n 7ownship Year
_�� .� FOR DEDUCTION FROM ASSESSED VALUATION 9-1 �
� Sfate Fwm 43709 (R11 / 6-09) A
•S uu � Presafhetl q' Departmeril af Lxal GovemmeM Finarxx
iNSrnucnoNS:
DEC File Mar1c
To 6e filed in person w by mail with the CowtyAWitor os Counry Recorder of fhe counry w1�ere th� �s � Fam med wiw:
Fi7irng Dates: 7J Real Properly Must file dumg the year (or which Iha deducfion is soughG � Counry Aud'rtor
2) Mob�7e / ManuFadured Homes not assessed az Real Property: Must fife dunng Me M1velve (��opt�plT�
belore March 31 af each year fhe deduction is soughG G�gSON COU ❑ County Recorder
See reverse side /or addRionel instnxGons a� qualifications.
Appfaant (oqrerw confraG buyer- see resvktiqris dr�k� seie) _
T - ois �rl �(ey
d r�s d re� p�apaty as af
1, avient ypar
rc�, �� �s n� i ner eua srwe m�e��
�� -Oa :3C� -c� �
Mo2qage/ Conbaa 4de6ted�ress unpaitl as ot
Mart3� t. wrtent year
I( name m remd is 6tferent Nan Nat of app6�n4 ��� Cebw
orcontraa
N rtuxtgagee or oontract selkr (number aM sfree4 ciry, state, aM ZIP coda)
name m asw,7nee or omer owner or nmer m trot�age
Address at assgnee (numbri eM saee4 �S: �, en0
Does applicant ovm proprJty in any oNu
munry N I iana?
❑ Yes ❑ o
Deaudion appro�red in ihe amouni of:
20 20
C
:C�?i
�
someane ahu tlian spase, trM'xzte wiTh ximm
iltaGe axnM
Yes ❑ No
Is ihe DroVenY in Question: MnuaM Assessed
[�.Reai ProPenY ❑ �^�Y�
��,.wae u.....e nr a
It yes, what munty.� � NTat T�
�'�iZ�]
� 10$ i��. °�,�
DC�\\'Ct' �iO.S!}01.�...,...
5i3y '.
CardNO . .....................
20 _ � 20 _
D�ate (mavN+, day, year)
20 _
lo
1 I We cerafy urWer the penatty ot perjury that the above arM foregdng infortnation is We and mrtect an0 fhat Me applirant is a resideni of Indiana and
owner I wntract buyer of the aforementioned property on date ap�wtion is filed.
�rewreSovmer2 NO name) . �� p�¢ (��ry. daY Y�a�
FW revtlent addres of appOwrt (number arM sbee4 �1; ffi�, � LP cotle)
� 3�3o r= S.KC<g f/<tibsf...�� .2i✓ Y
Pe�..an euthofm.d Cy EiEy exeated Pawei af AttomeY w by IC 67 �1-12-0.7
peJSOn (num0er arM sbeet �'/N, s+ate, erd