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""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship vear
_,. • FOR DEDUCTION FROM ASSESSED VALUATION
• State Fortn 49709 (R11 / 6-09)
�' f pr¢smbed by Deparimerrt of Lafal Govemment Firance
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ie a
WSTRUCTIONS: f1� �h
To be h7ed in person a 6y mad with the CowtyAWitor or Counry Recorder o/ the county where the property is bcatEnL � �Q9 L �
FAirg Dates: 1) Real Pmperty: Must (de durirg the yrearlor which the deduclion is soughG Counry Auditw
2) Mo6�7e /Manufectured Homes rrot assessed as Real Pruperty: Must file during the M1velve (72) mon fLis �
before March 31 of each year the deduction is soughG � Counry Reoorder
See reverse side lor additional instructions arM qualifications.
MP�i� �ow�rer wcontreC buye- See mi:nrSUns rn rev�e siYe) � � � �
T�Ois0irl Keynumber/kg3ldesaiption
a�� . �,- ;
�������, �rtga9e,�,����
Ma'd� 1. amrlrt year Ma� 7. current year
If nq what Is his ! her eract stwe of interest?
If name an �ecoid b Srtferent Nan Ihat of applkant h+Eicate �elow.
Name �f rtprtgagee ar wntrac er
• �Z
Addres ot mort9agee «wntraG sel (number aM stree4 �a% sb1e. aM:
Name o1 assignee w oMu awner or hdder of mortgage
AOdress of assig'ree (num0�ard sbee; tlty, sfafe, and LP mde
QT SW � 30 _.� - IC
Dces appficant own yoperty in any oNer tt yes, what count�?
2� _ 2(1 _
Sy�p��edCo�mbnudimr �
Y/
l.i
I I We cerOfy under ihe Ity of
owner I mntracl buyer of the ator
�/ ' (owne/st�d )
/� �
u0 msident adtlr�s of pp t(numd
�
Person authoraetl by duy execvted Pow
PddressotauWaaedpersrn (numbera
20
�
-OO�.07�-0 3.5
�aid a af MMgage / Contracl irWebtedrres
as d I Is�Nle
Yes L1 No
xtian:MnueltyAS�csse0
❑ nm,�nYa�a
a .�� A �
Whal Taring D'abicCl Has Ihis Eeductirn Eeen requesteO on p'opeity
. . tur artent yeaR ❑ Y� ❑
auorrort �R1� Qy � JAm E5
prAuE
� /�- y�9�
the above arM foregoing intortnation is we and cortec[ aM that ihe applirant is a resident of Ind�ana aM
property on date appliption is filed.
sbee; t�if}; state.
Date (mon(A, day,