Mortgage_Tichenor (4)'°� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun ip
s FOR DEDUCTION FROM ASSESSED VALUATION
� State Form 43709 (R71 / 6-09)
S,,,, Presaibed by DepartmeM of Lacal Govemrnent Flnance
F���RA�012013
INSTRUCTIONS:
Fwm fli ed wtth:
To be fi7ed in person or by mai/ wiN the CounryAuditor or Counry RecoNer of the county where the property is located. �
Filirg Dates: 1) Real Ploperty: Must file dumg the year /or which Ne deduction is sought �
2) Mo6Ae /Manufactured Homes not assessed as Real Pruperty Mus! file dunng the hvelve (12J months
6efore March 31 of each year fhe deduction is sougAt (�i I S C�Q) ��f TD
See reverse side lw adtlitional instructions aM qualrfications.
ADOGCant (owne( or contrarl6uyer- see r�CMCtiwu on reverse sitle) ^ ' /�
a�a van,e a re� �enr � m
A�mtl� 1, armY year
II no. what Ls li¢ / her e�mct N�are ot Intu�t?
m
fmt�qagce ar mntracc se0er
Nama of assignee w other owner
. I�
Mor(qage / ContraU 4deb1
Martl� 1, artent s*�
sn�er (numhe` and sfree4 uN. sb
o,m p�operty in any oNu
a?
❑ Yes No
Deduction appro�ed'vi tha amount ot
rl��
SigtaWre of C4iu:tyAWttor
t� J (c - l� � �
1 az N Mortga9e / ContrazY inde6tedness unpaid as of Is Ne
data of appGfala� legal
tt rnSrW w� wmeona oNer ihan spouse, indicata uY.h xfiom
periy in 9ueSUOn: Mrw�.
ProPeKY ❑ Annua
MoWle
D1'�11'CC 1i0....�4!�.�....
Z/P code)
c�►�a �io. ...... �....�3....
���.�� �iC�nof SS,�� ci� ��,�����,
❑ Yes
COUNTYAUDROR
20 _ � 20 _ � 20 _ � 20
Counry
�
Dete (monN.
TO
esde
omte(1
n No
61.
i I We certity under Ue penalry W perjury that the ahove arM foregoing infortnation is we and cortea arM that Ne applirant is a resident of Indiana arW
owner I contraa buyer of ihe aforementioned property on date application is filed.
I(ature (o fiAname) f Date (rtmN, daY• Ysa/)
, • �- ao�
?� � ��, � ,�� d � �
II ' nt eddr�ss of appyrant (numberand sLact, qity, sfate, aM LP ootle) ' .
Date (monlh, tlaY Y��
person ( umberarM snae; dry, stala, aM LP mda) .
N\� �