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"n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
, ; POR DEDUCTION FROM ASSESSED VALUATION
Sfa[e Form d3709 (R71 / 6-09)
•�' PresaibeC Ey Department of Laal Govemment Flnance
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e a
wsrnucnoNS:
k be h7ed in person w by mail with the CountyAuditw w Counry Recorder o/ Ne county where the property is located. F� �� p���1�
Frfig Dates: i) Real Property: Must file dunlg the year /or whirh tha deduclion is sought. AR� O C�IN� qudi[or
2J Mo6de / Manulactured Homes not assessed as Real Property: Must file dunng the tweHe (12J months
befora March 31 of eacA year fhe deduclion is sought � ❑ County Remrder
See reverse side for addltional instrucfions and qua/ficatbns.
n�ram( ror� D -seeresvknw�smre.ersesitle) n � � �� � �_ COUNTY AUDITOR
Tawg �ismr2
Assrssed vaM1re d real popeny as d
A/afU 7. anent year
aU
��i.L'1
u�diqte bebw.
� �I�
debte0ness unPaid az N Mwt9a9e / ntraU indeDte nrss unpaiG ��
date of appliration
It owned wiN sartieorie other than spause. udwale �
tJame of rtaxtgagee ar mno-an seoer n(� /�
� � iJ
Addr� of rt�orq7agee or mntraa se0er (num6er and stree4 �: s+ate, and ZIP code)
assignee w oNer owner or hdder of mortgage
�
Adtlress ot assignee (number arcl sbe — �' � — — - _ _
o���,,,�,P,h�a„y,� Dra�t�er NO. �13 —
m�,mr � i�a�? . . . . . . . . . . . . . . . . .. i?
❑ YES �
i �. —
Cac•d NO. .....� y��
Dr�umon aGW�+'� in tlre amouN oF. . • • • • • • • • • • —
20 20 _ 20 I 20 _ � U'
Si9riabae W CountyA�Witor
Yes L� No
Is Cie property in QuPStion: Anm�aP� Assnssed
❑ r� �,naenv ❑ nMUaMw�sed
Nas Uvs Cetludim Ceen reQUesteE on PmpenY
tor amea Wa/? ❑ Yes ❑ M1
20 20
Dale (monfh. daY. Y��)
I I We certify under ihe penalty of perjury Ihat the above and foregdng infortnalion is We and mrrect arW thai Ne applinnt is a resident of IMiana and
owner / mntract buyer of Ihe a(orementloned pmperty on date ap�cation is filed.
� (oxners (utl namel Date (rtw�tli. daY. Y��
W
W appCc�fi1,(number antl slreej aty, state,
person (numberarid stree4 tlry, stafe. aM LP rnde)