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�A STATEMENT OF MOR7GAGE OR CONTRACT INDEBTEDN unt Township Year
,a_,.. �� FOR DEDUCTION FROM ASSESSED VALUATION ��
�i' State Fortn 43709 (R17 / 6-09)
S� r Prascribed by Departmen� of local Govemment Financa �
INSTRUCTIONS: n 1� FiIC Mafk
t�N"
To be �/ed in person or by maiL . �I� Form fdetl wim:
Filing Dates: 7) Real PropeRy: Must be completed and dated in the calendar year lor which the deduction " t.
Must be filed with the County Audifor or County Recorder of the cowty where th m t�\�� Counry Auditor
on or 6e;ore January 5 0l the immediately succeeding ca/endai yeai. �( `( ❑ Couniy Recorder
2) Mobi/e /Manufactured Homes not assessed as Real Property: Must �!e with the tor ol the
wunty wAere fhe properry is bcated during the M1velve (12J monfhs before��1 U�1� year the
deduction is sought. G\o�
See reverse side toradditional instructions and quali�cations.
number/legal
Pssessed value W real qoperry as of
Mach 1, wrtent year
If no, what is Ns / her esacl share of interest?
�'�- /oG �Jao 70 � oa
euriD�on Record number Page number
�+c a � r� r.o �� �oia �
� I Contracl indebtedness unpaid as of Mortgage / ConVacl'uWeDteOness unpaid as of Is �he apd���� �e sole
aRenl year date of ap� tio�n1 i�/� legal oC�eoqfviiable owner?
�o��p VU� Id Yes ❑ No
If owned with someana other ihan spouse, indicate wiN whom
It name on remrC is difrerent ihan that of applicant, indiwte Debw.
Name of a55iqnee or other owner or holeer of rtartgage
AdEress of assignee (numDerand sVeet city, stafe, antl ZlPCOde)
pmpeM1y in any
s e properry in question: AnnualtyASSessed
Real Property ❑ MnuallyAssessed
DroPeM
DeEuction a00roved in the amount of:
20 _ 20 20 _ 20 _ 20 _ 20 _ 20
SignaWre ol Counry Audi•.or Counry Date (month, day, yea�
I I We certity under the penalry of perjury that the above and foregoing information is irue and cortect and that the appliwnt is a resident of Indiana and
owner / convact buyer of the aforementioned property on date application is filed.
Signat r wne/s ullnartre' Date (m'nth, da , yea�
�t. I a abl3
Fu0 res ent atlEress a00� (n Oere ef, city, s fe, e Z/P e)
9�f0 V�� S-�a�c %�� au ac�� 1`N �17�39
Person authorized by duy exacutetl Power of Attomey ar by IC G7.1-12-0.7 Date (month, day, yea�
Address o! au'Jwrized persan (number an0 straef. tiry, stafe, and LP coda) .