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^'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship vear
_ � FOR DEDUCTION FROM ASSESSED VALUATION
• Sfa[e Fom 43709 (R71 / 6-09)
�+ i p��y¢p py p¢pyrtrti¢N of Lttal Gwemrtrent Fnamx
File Mark
INSTRUCTIONS:
To be filed in rson a b mad with the Coun Auditor or Coun Recorder a/ the coun wFiere the ro F
ae r b b N a ae�N is rowced.
Fi7irg Dates: 7) Real Pmperfy Must fife during tha year for wh7ch the deducUon is soughG Counry Aud'rtor
2) Mo6Ae / Manufaclured Homes rrot assessed as Real Property. Must fife during the hveNe (12) months
before March 31 of each year the deduction is soughG �ef
See 2verse side (or add'rtmnal instrucliwu and qYalfiptnons. G�B
IAnofrantldvnerormnlraC6wec'.seerc��c8�lson versesidel .
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Abrtgage / Contrarl4debtetlness unpaid as af Mortgage /�on� mEet
Maith 1, curtent yeer tlate of applfatioo.� /
mno-aesener �
Address of rtwrtgagee or mntracl se0er (mrrJfer ard sfree; rdy, sta'e, aM LP mde)
Name of assignee
Addmss ot
rtprtgage
.F:1/]1
Dces aPDlipnt own P�oDenY in any othu'- _ —� �.._: '_'_-_
pyuw:., i,..+:.._-.,� — :.
- Dra���er-i�'0...'.a.�.�..�.�.......
D
- Card 1\`O. .. 3107......... �
� �a, 900. —
numbel I Pape number
unpaid as af Is Ne aOPOrant the sde
legal w equ@able ax�wlt
� ❑ Yw ❑ No
someone oNei ihan spouse, iMimte wIN xiu
Is ih DroGenY in questic
eal PfoPertY ❑
WhatTa�dng D¢trict7
cour+n auorzoa
zo zo
Has Ih's deducGOn been requesteE m property
�� aRe^� ��' n .,_ _ n �
zo_ i Zo_
yea�
I 1 We cerufy under Ne penalry of perjury that the above and foregoing infortnation is true and cortect arM ihat the applicant is a resident of Indiana ard
owner I mntract buyer of the aforemeirtbned properry on date appliration is fiied. �
7raNre (uwneYs fu0 name) . Date (/rmtA daY. l'me�
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�I tlent ofappG�antfnumbereMSLee4dty,s7ate;andLPcode) _ , .
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Puson author'vi
prJSOn (numberarN sneat ary, sbte, end LP code)
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oa�e c,�,n,. day,