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^'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ovmship Year
_ • FOR DEDUCTION FROM ASSESSED VALUATIO� ��
n Sfate Fortn 43709 (R71 / 649) �
,�' � presafped by Oepartment of Lod Govemment Frarxx
� File Mark
INSTRUCPONS: 1
JAN F�„ fl�,M„,:
To be filed in person or by mail with the CountyAUditor or Counry Recorder of Ne county where tAe prope� ��.s�ted.
Fi7irg Dafes: 1) Real Pmperty Must fi7e during fhe year for which fhe deduction is soughG � Counry Auditor
2J Mo6Be / Manufactured Homes not assessed es Real Property Must fi!e dur� fh�hv e nyrs
before March 31 of each year the deduUion is soughG �2Q�{ County Recorder
SeereversesideJcr�additiunalinshuctbnsar�qualfications. G�BSONCOUNTYAUDITOR
i G`� tcey Aumeer � �epa� Q ' tion
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M�sessed value of pfaperty es Mortgage /
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�f no, ,vhet fs his, he� eratl �we �, in�i�l?
11 name on remrd is d�aeni Nan that of aPP��t'oMilate 6ebrr.
Name of rtnrtgagea of COn0af1 xtler
Aedress ot mortgagce «contraa uUer (num6er en sveel, ctiy,
Name af assi9nee or oUx+owner or hdder of mortgage
Atldrass ot assi9nee (numDar and atreeG ciry, state. an0 LP code)
Dce5 eppfimntovm om�°"'--
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a pi•���'er i�0.....
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Card 1O• .............
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0 3�-�00 -cL't�. 5 �8�od i '�° �ia "��a4a
nde6ledness unpaid a d Mortgage I Con7a�l'uWe6tedness unpaid as of Lv ihe appGnnt tha sak
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ri�? What Tad�g D'avirlT
couNrrauorroa ,
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I I We certify ufWer the penalty of perjury that the above arM foregoing intortnation
owner I co�pact buyer of the aforementioned property on date applicaeon is fiied.
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person (numbera� saeeS �ify, sbte, aM LP code)
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Is Ihe Praperty in QueSGOn: Mnu
❑ RE21 Ro�J2t1y ❑ AMtl3
MoWle
Has ihi5 dedudion Eeen 2qugted m P�openY
mr wRem r�� n.,_ _ r'�
Zo_ i zo_
Date (rtio�rth. daY• a �
� i—�'—a
correc[ arW Nat Me applicant is a resident of Indiana and
oa� (�m. day,
QdiB �ll1'Uli�lr �3y �88�