Mortgage_Virden (3)P
"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship Year
__ . FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R71 / 649)
�' ? Presaibed Dy Departmenl ol Local Govemment Frunce
ar
ie a
INSTRUCTIONS:
To be filed in person or by mail witA the CounryAudito� or Counry Recorder o! the county wf�ere the pioperty is located.
FiTing Dates: 1) Real Property: Must file during the yrear lor which the deducLOn is sought.
2J Mobde / Manufactured Homes rrot assessed as Real Pmperty Must file dunng the M1velve (12) monfhs
betore March 31 of each year the deduclion is sought.
See reverse side for additional instructions arrd qualifications. GIBS
MW��t(owne�orcoDVartDUYer-s�§resnictioacmreexrse5tle) _ " ' .
�
MarUt 7, i
If no, xfiat is his 1 her eraa share ol interesl7
If nama on recortl is SMernnt
5
of �9a9ee or mntraa
� CaunryAudimr
1/ legal oeyFnpUm Recprp num6er Page numDer
-/D-3lo-Yoa-pD��Sa7-oz/ l3 5�(0
Mort9a9e / Contrars'vitlebtetlness unGaid as N Mortgage / ConSaft mEebtetlness �mpaid a o1 Is Ihe ePP�� Ne sde
March 1, arteM year date of apPfication legal or epuitable o�meR
a oo v ❑ Y� ❑ No
tt owned vriN someone aher ihan spouse, irMimte witli wlwm
end sbeel, rdy, stale, aM LP oode)
Name ol assignee w oNU ovmer w talder ot mortgage
MC2ss of assgnce (numbar eM Stree{ tlty, sfate. eM LP Cof
SE 3�-�-
ppes eDP���� � P�PeRY �^ any olher If yes, �
munyinlMiana? � .. � ..
2�
aoyo�e m me a�� ur.
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Autlilor _ , �
, �1 }- fi L,
couNn nuorroa
zo_ zo_
County
�Is M°e Oroperty in Ques6on: MnuaOy Assesud
�r�eal ProPenY ❑ �!��Y�
:tricl? I Mas Iti�deEUrlion Deen tequesteE on propuly
_ _ __ �'
= VI12: ��IJ� 1 Ri�y �J
Q/E2yN J
zo _ / 3 - S%(�,
I We certify under the penalry of perjury that the above and toregoing infortnation is we and correct antl that Ne appii�ant is a resident of Indiana aM
mmer I contracl buver of the aforemerrtoned DroaeM on date application is filed.
FWI residenl adCr� 01 appliran� (numbar ard sLee4 dty, sfate, emtl Z1P code)
�Bb$ w . �}Sc� S � C�..��e.�-,'Sv.\\
Peison auNwaM by duty ezecu[eA Power of Attomey or by IC 61.7-72-0.7
person (numDer aM sbee4 �$: sb(e, antl o�' ca
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