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"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun o ship ear
_. : FOR DEDUCTION FROM ASSESSED VALUATION
• Sfate Form 43709 (R71 / 6-09)
�' w. �� Prew�bed Ey �ePartrtrent af Local Govemment Frwce
INSTRUCTIONS: F�
To 6e filed in person or by ma�i with the CowrtyAWitof o� Counry RecoNer o/ fhe county where the properry is bcated.
FiArg Dates: 7) Real Property. Must fJe durirg the year /or which the deduction is sought � �� �
2) Mo6de /Manufactumd Homes lrot assessed as Real Pioperty Must fife during the tweHe (12) months G IB OI�OI�b��Tj�}fi
6efore Ma2h 31 of each year Ne deducROn is sour�hG �
See reG�se side /or add'tional instrucf(ons end qualfications.
� t(ow.�w�contrarl6uye�'sep�gnfmr�az°Are"ers?s?Ma)
T" i triG Key r� h¢r / le rsaiP .
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Assessed rdue d real P�ertY as a( Mortgage / Contraa 4
Mardi 1. arrrnt }ear Marth 1, curtent year
tl ro. what fs his / he` eracl sham of interrst?
If name on recn�d is dtllerent Nan Ihat af app6�n1, hWirata belrnr.
Name ot mortgagea « contract seller
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qed� m �� «�o-aa seuer �n�.ard �c ' , �
Name a� asUryiee or otner owner w ndnar ot rtqrtgage `/
PAEm_ss of assgnce (number arM streeG dry, swe, eiM LP catle)
Dces apPlimnt wm property in sny oNer If yes. what count�?
munrylnlrqiena7 � Yes ❑ No
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f as of Mortgage / ContrafY'uWe unpaid as d Is Ne eppGrant ihe sole
date of app�ca kgal a equitade wmeR
� �j ❑ Yes ❑ No
rc ovmea wi� someo�re oNer than sPO�. indnate wkn xTam
Is tl�e pmperty in QuesOOn: Mnually Pssessed
eaI Pivperty ❑ Armualy Assessed
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a�q o�maa Has Nis tledufYion been requested on pmperty
�� ��� � ❑ Yes ❑ No
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Counry Date (monM. deY Ypa�
oregning information is W e and wrtea aM that Ne applinnt is a resident of Ind�aru aM
: application is filed.
�. � // Date (month. day, lvs�
Puson authrn¢ed Dy O�dy executed Pwer af Atmrt�ey or by IC Gi.t-12-0.7
Pddress of authw'¢ed person (num6ar antl sbeeS �+�Y, sta�e, and ZIP cade)
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