HomeMy WebLinkAboutMortgage_Bezy^'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
• FOR DEDUCTION FROM ASSESSED VALUATION
� Sta[e Fortn 43709 (Ri1 / 609)
�' � Presaibed by Departrtcent of Lacal Govemment France
Fi a
INSTRUCTIONS: F ���:
To be filed in person or by mail wiN the CountyAuditw or Counry RewNer of the counry whe2 the property is located. (�',
Filing Dates: i) Real Property: Must file dunng Me yearlw which the deducfbn is soughL M �� Cyenry Auditor
2) Mobile / Manufactured Homes not assessed as Real PropeAy: Must fi/e dunng the tweHe (72) months
before March 31 0l each year the deductnon is soughG C. . unty Recorder
See reverse side for additional instrucUons arM qualfications.
qppficapl(owner orcontrart buyer - see reunrbou on reverse sde) Y AU DITOR
li
T'� pisp� Key legal desaiptim Remrtl numEer Pa9e numbel
-a3-oa - oo - ooa .�003- o a �� � � 1
vaWe d real D�P�Y as oi Mortpa 9e / Contraa inde6tedness unPaid as W Mort9a9e / Cantrer2'uMeMedness unDaid as d b Ne ePP�t the sole
7, � y� March 1, artent yeer date o( aOP�� kgal w epuitaWe awnnY.�
S% O O I� ❑ Yes ❑ No
11 rw. whal'a h's / trer axact share ol interest? If avmed wiih wmeone other tlan spouse. iMirate with whom
tl rwrie on remrC'a QMe�ent Nan ihat of aPpMant, uNicate Celmv. Is the property in puestion: Mnua�y Assessed
�j2eal ProPeilY ❑ AtmUaily Assessed
Modle Flome IC E1.1-7) '
�ame at mort9a9ee or ronvarl seller `
7
Addiess of mort9a9ee ar cmtratl seller (nurti6er and stree4 �: y�e, aM ZIP tode)
Name of assignee a oihrl awner w holder of rtqrt9age —. _ "_— '
AdEfess of assgnee (numberaM street ary, s+ate, and Z/P code)
Does aDWiiant avn prope�ly in any oNer If yes. what munry? What i r` O I,! ..'. ...... Weny
counryinln0ena? D1�.�1\i'�.'I� �Q....
❑ Yes ❑ No ' ^ � ❑ No
COUNTY AUDR� ^ 11�(1 lt 0. . .. • • • • • I:I• . . . • �. •
OeGUCtion aPPravad In �he amount of. ��• ���/ �
G wa
20 20 _ 20 20 20 _ 20 _ 20 _
SigreWre ot Cwmb AWitw Caunry Date (monlh. daY. Yea�
I/ We certify urWer the penalry of perj Nat Ihe abo ard foregoing infortnation is We and cortect arM that Ne appliran[ is a resident of IMiana arW
owner I conVaG buyer of ihe aforeme tloned prope on date appfication is filed.
� aWre (ovme MI me) Oare (month, day, yea�
Full re4de t Aress o1 appGranl umber and shee4 al: ��e, aM ZIP mtle)
s s-� T �/7(�39
Pelson author'v.ed Ey OWy ezewted Pvxer of y or by IC G7.1-12-0.7 Date (monN. JaY, yea�
AOtlress of aWror¢ed per:.on (�um6e� aM stree; ciry, state, aM Z!P code) .
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