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"'nv STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
_ % FOR DEDUCTION FROM ASSESSED VALUATION
' State Fortn 43709 (R71/6-09)
,�' � presm'6etl by DepaRrtrent of Laal Govemment Firwce
INSTRUCTIONS:
To be fiied in person w by mad with the CourrtyAUdifw or Counry Recorder o/ the counry where the property is Iacated.
Fifing Dates: 7J Real Property Must tJe dunng the year for which tha deduction is sought.
2) Mo6r7e / Manufac[ured Homes irot assessed as Real Ploperfy Must fi!e d�ring the hvelve (12J months
befae March 31 0/ each year the deduction is stughG
See ieverse side for additional instrtrcGons erM qualifications.
AppG�t(owne�armno-aebuye�seeresuirboraonreverseide) ..� � 1 . 1GIBS
rapr�y o4so-wc icey �wmoer i i«jai e�cc
a�-i�-3
Ass�sed rdlu f� poperty t Mortgage/ Cont
Maftl� i. ai year Mamh 1, curteni
If rw, what Is his! her e� share of interest?
It name on remN's Nflerent Uian that af appbpnt, rt�Eirata 6ebw.
� - yoo -voo, 3 � - o �
act 4dehtedness unpaid as ot Mortgage I Contrac[ m
year date ot app�tion
of mu[gagee w mntrad se0er (num6Pi ard sLeeL �}: slate. aM ZlPcode)
name rn asvgnee or wwr owner w noiaer rn(mtgaye
Address ot assignee (numberarid street dry, slate, end LP catle)
Does eP0lwant own property in any oNer If yes. what m�nry7
D�uc�on app�wed In ihe artrount ah.
Wtat Ta�dng D'¢trict?
� L`NiY)'b Auditor
❑ County Recorder
COUNTY AUDITOR
rtf num6er Page numbe
iegai or eqwrade amert
� y % ❑ Yes ❑ No
s'pouse, IMimta with whom
Is wopem i� question: avn,aM wssessee
Real PfoPenY ❑ �!�Y � . ' '
�'
F���� ��
Dra�ver iYO..�d/ a�
Card�7�. . . � / (� 3..' ...
I �/� �Op ep' ..
20 20 _ 20 _ 20 _ 20 _ 20 20 _
u+enne o Cowry Auettor . r Counry Date (mmfl+. tlaY. Y��
I I We certity under the penatty ot perjury that Ne above and toregoing infortnation is We and corteu and that the applinnt is a resideni of Indiana aM
owner I contract buyer of the atorementioned property on date application is filed.
InaGUe (ownrls (u0 �me) /� � Date (monH6 daY• Yaa�
t W revaen[ aaares w appurant (numcer ano aty; atare, elq LP ooee)
ivaa�s �o�rl,J osr��;�le IN �-17Lo33
Pgsm auftro�aed Dy dWy ezecu;ed Pow¢r otAtmrtiey w by Gi.7-12-0.7
AECress W aufha'sed person (numberand sDee4 �Y. slate. antl LP cotle) ,