Mortgage_Joyce^�n STATEMEN7 OF MORTGAGE OR
FOR DEDUCTION FROM ASSES�
" �� Smte Fwm 43709 (R11 / 6-09)
,' � Presrn"bed M DeP�N oi lnd Govemment Finam
ULI. B •• �°•�
INSTRUCT70NS:
To 6e fifed in person or by mail with the CountyAuditor or Counry Recorder of the coun��where rty is located.
Fifing Dates: 7) Real Property: Must file during the year (or which the deductlon is wught.
2) Mobile / Manu(actured Homes not assessed es Real Prapertv: Must�l�p¢1{e�TA{� months
before Ma�th 31 of each year the deduction is sought. � GI BSt�
See reverse side (o, additionel instructions and qualifications.
MP��(owrrerwcprr�ACbuyer-see mreversesktej
Maid� 7, aa�ent yrar
If ro, what Is his /
File Mark
Farm Aed with:
Counry Auditor
❑ Counry Recorder
ion Record numhel PaBe m�mbu
- oo�8'K� d a.6 ao� a �v
rari IrdebteOness unpaid as o( Martgage / Con� inde6tedness unpaid as ot is Ne eppl'irant tha sole
t yee(r, —7 Eate of appfi�tion legal or equltaCle ovme(1
� 7 � / ❑ Yes ❑ No
It nartre on remfd's 6lferent Nan that at aOP��L �dinfe Eebw
mortgag�tractse9er
���
N�agee ar mntraa se0er (nwMe� ald st
assignee or oMer owner or holder of rtprtgage
of assg�e (number and street tlry, s1afi, anc
�ty, sbfe, ard LP code)
Oaes appiitant own property in any oNer I It yes, whal county7
counry in Indmria? ❑ Y25 ❑ No
20 _
SigraMe d Cow.b nu0ncr
�
COUNTYAU
20 _ � 20 _ � 20 _
Counry
someone oUier �han spouse, indirate wRh whom
Is ihe GroPertYm Vuestion: Mnua�NASSessed
� Real Pm'�_riY Q Nmualy 0.55essed
. - n,m�ie � nc s
E"��ct � —
a-- �'
D,-1,ti���� �io..... ��la
Card NO. .....��� �
�_ � p—
Date (/rronth, daY. Yea�
�nY
❑ No
20 _
I I We certify under the penalry ot perjury that Me above and foregoing infortnation is true and cortect arM Ihat the applicant is a resident of Indiana aM
owner I mntracl bUyes of the aforementioned property on date application is filed.
rd}; state, aM LP catle)
author¢ed persan (numberaM svee4 �Y. �re. aiM LP cotle)
o�? (r+,w+rh. dar. �tl
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U�t?'
