Mortgage_Hageman^'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS un . o �p Year
_ FOR DEDUCTION FROM ASSESSED VALUATION
. � StatB Fartn d3709 (R71 / 6-09) � .�
S,,,, Presaibed Gy DeP�reM of Lacel Govemmenl Friance
INSTRUCT70NS: FED �'I��
Fwm t�ed with:
To be filed in person or 6y mail with the CounryAudito� or Counry Recortler o! the counry where the pmperty is located.
Fifing Dates: i) Real Property: Must file durirg the year /or which Ne deduction is soughG unty Auditor
2) Mob�7e / Manulectured Homes rrot assessed es Real Property Must file dunng the fwefve (72) month
6efore March 31 of each year the deduUion is sought. G�BSON C UN A�B�°fder
See ieverse side /a additional insVUCtions and qualifications.
pppGpnt (ownar w cov�trart buyer' sye resMrlD�ns m reverse sile) _
A�s¢sed value oF �
MarM 7, GurerG yrar
ro.
rwria m recad is SAfgent �han ihat of aPP�^�. ��te Delow.
Nartre at rtnrtga9ee ar s�er
�
nearess or �,ortyayee «m�,raa �u�r p
Nama of assignee or other owner w hddi
Ad�mss ot auignce (number aM sveeG
Does epplirant wm pfoperty in any other
munry in Indiana? ❑ Yes
DeducCOn approvetl ui ihe an
�
swi,an,rea can,n nwiwr •
shee4
tlry, stafi, aM ZIP cotle)
If yes. what munl�/t
�
Retad numOeJ
- 300 _ oo,� . a 3�5 -
�9a9e / Canraa uMebtedness un0aidasT Is Ne eGW�t Ne �
i of applitation legal w equitade owneR
�/� SOs ❑Yes ❑No
sonieone ather tnan sPO�. �M'�te with wiwm
�C�e PmPenY in 0uestion: MnuaOy AssesseE
Real Property ❑ MnuallyAssened . . .
GL G
vnt of. ' �/, �1 "" � � �
Y�1 V✓
l �
�- 13 , _�
Has Uis tleduUirn Oeen repuestea m proprtry
fwwrrentyeaR ❑ Yes ❑ No
zo_ , zo_
� t�. �r. r�n
I I We certify unAer the penalty of perjury that the aGOVe and foregoing information is true and cortecl and that the applicant is a resident of trMiara aM
� owner I conhacl buyer of the afwrjmentioned prop� on date appliptlon is filed.
Sig�ature ( e/ , remjl .� ' Dale (nmN, daY• Y'�a�)
i�a� � ,
Pdr n auUqr¢ed by Euy exeaitetl
Address ot authoraed person (num
by �C 61.
erW sGeeS �Y. ��.
y 7 G � �
Date (rtpn�h. daY. YE
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