Mortgage_Cox (10)�
�pUGTo'. a,(�-14-r$_acb�ool.(oaa-oo(o
^'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7owi
,__ , FOR DEDUCTION FROM ASSESSED VALUATION
. . Smte Fortn 43709 (R11 / 6-09)
� j Presoibed by DePa�nl of Loml Govemrtrent Firence
le N
INSTRUCTIONS:
To be frled in person w by mail with the CountyAuditor or Counry Recoider o1 the county whe2 the property is located. �
Filirg Dates: 1) Real Pmperty: Must file dunng the year for which fhe Ceduction is sought. ��
2) Mobile / Manufactured Homes not assessed as Real Property: Must file dunng fhe fweHe (12) months NQ � r},
6efore March 37 of each year the deduction is sought <Lp�
See reverse side for additbnal insVUCUons and qual�cations. �,_,
�o o Key numDnl / M9al a¢Wi�iq� ` _ I ' I ' / (J _ ^ � /^ oO/•
(Jl Y� �_%, u(
Msessed value d rnal prapgtY ��9a9e / Contrarl inde6letlness unpai0 az a( Mortgage / Convari'va
Mafd� t. wrent Y� Mart�h 1, a�rtent Y� Eate oE�fication
�
II no, what ts his ! her e� share ot intemst?
If name on 2mrt! 5 tliiferent than Nat of apP�^l �dicate bebw:
Nartre of rtmrtgagee or contract seller /�
� c
AAtlr� W rtartgagre w cantraG seAer (mm�ber end sLeeS u(y. s+a�.
Nama of assignee or othr! owner or hdder of rtartgage
Address o( assignee (numbu aM atree4 my. s+ete, and Z/P cotle)
Does e�ifaN o�m ryoperty in any other If yes, wha[ a
counry in InCana? ri .. r� ..
in Ne amount of:
20 � 20
I I We certify under We penally of
owner I contrad buyer of the aton
If ovmeC wiN
COUNTYAUOROR
G/gSON n � �
ali�l� 3
f:7!:'. S1a7
�te0ne55 unp2tl 23 Ot Is Ne BppBfani Ne sde
� (..iCJ �al a M�iraNe amen
❑ Yes ❑ No
spouse, indirate wkh wfwm
Is the prape`ty in 9���^: �nuaDy AssesseE
❑ Real Property ❑ Mnualh� Asseued
Dra�r�er 1\'0......duu .1....
Card NO. .....rJ. 9SJ.� ........
�A ����ObU.Uiv
20 20 20 20 _ 20 _
Counry Da�e (mon . daY• Y� A
� 1—� 0
that Ne above aM (oregoing in(ortnation is We and corte<Y arW Nat the applinnt is a resident of Indiara aixi
ned property on date applica[ion is filed.
/ Date (monih, day. yen�
� //-.20- O
E a0tlress of a�cant (numbar and street, riry, te, aiM Z/P cotla)
17 1�1, M�r,� �A�L.�ND e� �/ �N �%��
auNU¢M Gy tlWy esecuted Powef o(AVameY a�' IC 6t.t-12-0.7
s of aWia'ved person (number aM sbeet, city, sfata, an0 LP tode) .