Mortgage_Stotlar' ^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship vear
__ • FOR DEDUCTION FROM ASSESSED VALU�i� ��
• State Form <3709 (R71 /6-09)
,„� j Presmbed M DeG�neN of loW Government Fu�arce
File Mark
INSTRUCTIONS: ��n'I 1 C
To be filed in person or by mail wdh the CounryAuditw or Counry RecoNer o/ the m[tpry ud�e� �B Fortn Aed m:
PeAY is bcated.
Fifilg Dates: 7J Real P/operty: Mus[ file dunng the year for which the deduction is soughG County Auditor
2) Mo6Ae / Manufactured Homes not assessed as Real Property M�st hie.d4�we Ive (12) months
befae
�
If �wne on remrd a 6flerrnt Van that of aPP�L ��� Debw
Name of rror�qa9re or mnttact seller
Add2a of rtiortgagce a contrad se0er (num6eren
Name al asiryiee or othu owner w hdder of rtqrtg
Address of assgnee (numberand sheet dry, slafe,
�oes eppluant own yoperty in any oNer
muntyminQ'rdria? ❑ Yes
20 _
Signature d Co�mry AWitor
20 _
Page
4de6tedness unpaid a of MMgage I Con� mde6tedn¢s �mpaid as o1 Is ihe appfrcanl Na sak
date o( appGCatim tegal w equitahie mmM
�O� ❑ Yes ❑ No
If ovmed vriM someane other Ihan spouse. IMkate wOh w�om
shee4 �: state. aM ZIP code)
If ye5. what
No
I N
Is ihe P�veM in Guesrion: Mnua�Y A-se�ed
� Real HvPenY ❑ ?J?�!��'1 �
�(- �- � ��
- �s�,�y � � -
P�°UT3 _
iq ' q - b�a � ''��
d ,l�r��
l.7'
COUNTYAUDROR
20
Counry
� I ��h��
20 _
�Sr SEVU �'1
20 20 _
Date (monM. daY,1'�a�
1 I We certify urWer ihe penalty ot perjury Nat ihe above arW (omgoing intortnation is true and correc[ arM that the applirant is a resident of Imliana a�
owner I tontraCt huyer Ot �he aforementloned property on date appfitation is filed.
verson
S
(number antl stleef, oly,-�taraxd2lP code)
tid-er �'� �,i- &��,�I,, ��v Y�dv
� a�r ornu�y o� cy �c s,.,-,z-o.�
o(authw'sedperson (numberarMsbae4tlry,
Date (monN. deY.