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"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun wn ' Year
.,_ _• FOR DEDUCTION FROM ASSESSED VALUATION
.• SFata Fam C3709 (R7116-W)
�' ,,,, Presaibed �y DeparimeN af LocW Goremment F�rrz �
File Mark. �
wsraucnoNS:
b be fiied in person or by mail wilh Ne CountyAUditof or Counry Recorder of the tounry whefe the property is bcated. �
Filirg Dates: 1) Real Properry: Must file dunng the year fru which the deductlon is sought q un u�
2) Mo6de / Manufactured Homes rrot assessed as Real Property: Mus! file dunng tAe twefve (12) months
6efore March 37 of each year the deduction is sought ��
See revers�ide Ior additbnal instructions and qualfications. GIBS
MP�m wxr or oontrdrl bul' ' �i Ry�s °B{�i'e�� �e) . _ .. . .
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Y�
ro.
narre m
Name of rmrtBagee or crntract seUer
i� -.��a - o�o.
�/ ContralY inde6tetlness unpaW as o(
artent year
Address o1 rtartgagce or oontrxl sWer (numbe` aM�heel, cdy, sta.e,
Name of assignee w otlreJ ovmer w halder of mortgage
Adaress of assignce (number and sVee4 mY. sfdte, entl ZIP code)
Does applimnt ovm yoperty In any ol
counryinlMianal ❑ Y�
Deauctlon approved in Ihe amount ot
20 I 20 I 20
; -Da " - � � � Yy5'�
MMgage I Contra MeEness unpaid as of Is Ne eppOranl Ma sole
tlate of aD�'_'.,�xi��� ��f� �ega� or equitaNe owneYt
�J . / / '(. J ❑ Ye5 ❑ No
It owneE wiN
r�. i r i:`.� _v r. ri c. r�
20
mdrcste wiN whom
peny in Question: Mnuelly Assesse0
PrOpefly QArmuallyA55e55ed
'
' Drawer NO....°.��. 0.......
yR9U
- Card NO .....................
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N I 'LU I TO
1 I We certify under Ne penalty of perjury thai the above aM foregoing infortnalion is W e and correct and Nat Ne applipnt is a resident of Imliana a�
owner I contrad buyer of the aforeme�rtoned property on date application is filed.
�^afi�je(ownc/sl�imrtre)�A / Date(nmfi,daY•Y��
'Ya�IL htuc— Tr,n
tluy exew[ed PowerMAitortiey or by IC 61.1-12-0.7
MEress of autha'¢N person (numDeraM SLee; dty, state, aM LP mae)
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