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"'�+v STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
.,__ • FOR DEDUCTION FROM ASSESSED VALUATION
State Fam 43709 (R71 / 6-09)
� � Presm"bed by DepartmeN of Lod GovemmeM Fuwwe
��«• File a
TRUCT70NS: �gh�
To be fi/ed in person w by mad with the CountyAUditor orCounry Recwde� o/ the county where the properry is located. F fi y 2� �2
Fi7irg Dates: 1) Real Property: Must fJe durirg Ne year Por which the deduction is soughG n Counry AWitor
2) Mobi7e /ManuFadured Homes rro[ assessed as Real Pruper(y Must file dunng the M1relve (12) months Cr�
before March 31 of each year the deduclion is soughL LJ �
See reverse side lor additional insfruclions and qualfiptions. GIBSO
��.���� �i.r��a> � � , �x)
��ah�e d real �aperty as ot
arreftl year
11 m. whai fs Itis I her exad share OI Nteresi7
If narne m�emd'a 6lfuent Uan Nat ol app
Mame ot mortga9ee or convxl se4r1
�
Addres of rtnrt9a9ee w contraG seller (num
mirega �saipvrn
- 00-d�a. /�3-6d
IMoKqage / Conbact 4de6tedness unpaid as o( Mongage I Contraci
Marrh 1 airtertt year date af legal or eqwtable amM
Q OO � Yes ❑ No
IF owned witn someofre Man spouse� md�te Wrth wham
as o( Is Ihe app0�nt ihe sole
ard streeS ��t slate.
Name of assigriee w othrJ avmer ar hdder of mwtgage �
ACtlress of assignee (number aM street tlry, s+afe, and Zll
Ooes appli(ant own p(operry in any oNer If y
munry in InC'aria? ❑ Y�
❑ No
DraucEOn appraved'ui ihe amount of:
20 20 20
Gi�I �7: i� 7a[�171 iil 7
20
_r
I/ We certfy under Ne penalty of perjury that Ihe above and foregoing infortnati
owner I contract buyer of the aforementioned property on date application is file�
�c. �.,��-
u6+esident address W a nt (num6er M�q et, dty, stdte, ar�tl LP ca
`� !'03�1-1 S. Csr�oc�,.� /G� u��
Pelson auUwfaed by dWy exea;ed Pawer of Atlamey w by IC 67.1-12-0.7
�
fa c
20
x+ry m Vuesoon: MnuaDyAsse�ed
P(operly ❑ AmlualyA55essed
20
:�a o� v�r
Yes ❑ No
D1':l\\'CI' ��.•.�OI�, , Wianaand
tJf I�•V �.......
��,.� �p�..� 31,�8 � - "",
y i�3y
Date �rspnt�. Oay Y�
DC1S011 (numOelarMSbEEC�:StdtE.2MLPCOtl¢) . — - '_ �. -_