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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun awnship vear
__ FOR DEDUCTION FROM ASSESSED VALUATION �
� Sfate Fortn C3709 (R11 I 6-09)
�,�,� PresaibeO M���ri ol La�l C+aremrtieM Frente
wsraucnoNS: �Y10�
ef�:a�-ao-�5-aoo-ooi.�yl-oo� FileMark
Farm Ned wiN:
b be filed in person or by mati wifh the CounryAUditor or Counry Recortier o/ fhe counry where the property is located.
Filhg Dates: 1J Real Property: Must file dur6g Ne year for whicA Ne deduction is soughL � County Auditw
2) Mobde / ManuFactured Homes not assessed as Real Property: Must file during fhe hveNe (12) months �nry Recorder
6e(ae March 31 of eacA year Ne deducc�on is sought.
See reverse si0e 7or �JQ'rtionel inshuclions end qualificatons.
7asop�D�d l �Y � � k9�Q�
d / o< -c
AsseveE val e d real po ty as d �.brtpage I Cont
Mmch 1. arinR ym Marr3� t wrtenl
If ro. whal Fs ttis / trer e�Y share af inffiresi7
tt name m mmd is Nfferent than Ihai of aPP�C Indirate bebw:
Name of nnrtg�e or mntract sWa � ��/
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Pddress d nnrDpgee a oontrae se0er (nurt�er end straeR
Name of assigncre w aNa owner w halder ot martgage
Pdd�ess af aag�ree (number aM streeG �Y, stete. ad LF
pcey epp�rrt awn P�PMY in any otha
munry u� IMarw? ❑ Yes ❑ No
De�ucUOn approred 4� tlre amaun[ o(:
�° 1 � i3°=
se�ame
� I I We ce' . er th penalty ot perjury
wmer I mntracl of Ne gfaementic
a,�
cpdel '
�
�qage I Contraa mde6teAness �mPaiO as of Is ihe aPP�rant Cro sda
i o( appfma�on � a �� �
❑ Yes ❑ No
w�re other Nan spause. uW'Kate with whan
Is tM WopeM1y in QursGm: MiWaDy Ass�teE
� Reai RoPeRY ❑ ?�!��� J� . .
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Has inis de�uaim Oeen requestea m proprly
��� ❑ Yes ❑ No
2 / > 2°— 2°—
� ca,my oa� lmwn. ea . n�_�U
he above and fwegoing infortnalion is We antl cortect arM ihat ihe applinnt is a resident of IMiana aM
�roceM on date appiicatlOn is filed.
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Pcson auCqt�A �y Mry ezecu[e0 Paxe+ot nvunaY w 1 61.
MCress of autlror'veE 0� (num0er antl stree4 d1Y. sb(e.
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Date (rnortN. DeY.
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