HomeMy WebLinkAboutMortgage_Brickley^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun�
; FOR DEDUCTION FROM ASSESSED VALUATION
Stata Fwm 43709 (R11 / 6-09)
�' Presaibed by DepartrneN oi Lad Goremrtienl Fi�arke
INSTRUCTIONS:
k 6e fifed in person w by mail wifh the CounryAWita or Counry Recorde� of Ne counry where fhe property is located.
F�ing Dates: 7) Real Properry: Must file dunng fhe year lor which the deductbn is sought.
2) Mobr7e / Manufactured Hwnes nof assessed as Real Properfy Must file durirg the fweNe (72) months
6etwa March 37 0/ each year the deduction is sought.
See reverse side for addilional instructfons and qualifications.
A[np C Coupy/�udecorder
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IAp awrrerarcrnCaC6N'e� s �estrrtunsmreversesde . Ca'B$ �\\
' ON COUNTy q�p�
T District Key rvunber / legel Cesaiption Record numh� Pape numEpi
a6 -a3-o�-300 -oo . a -o a If �o�
va4re oF real pmperty as ot Mortpag e/ Contraa 4drbtedneu unpaid as W Mortpage / ConvacY cbehtedness �mpaid as d Is Ne eppGmnt Ma sok
i. amm ym Mem3� 1. a�rtent yeer dafe W aDP�� legal «epuitade owneYl
' � 1�. CJ O Zi ❑ Yes ❑ No
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Wn ihat W appOCar� mtlicata Delow.
Name of mxtgagee ar contract seller �� Q�
�7
Add2ss of mortgagre ar contratl u�er (numher end sbael, ctty, state, end LP cade)
rvame o� assgnee w ovms owner or naaer a� morcgage
dimnt ovm propelly in any i
Inaiana? ❑ Yes
Deduction aPPmved'c� IFre amount
No
someone other than spouse. iMicate wtth MMm
Is tlie ProOertY in Ouestion: MnuaM Assesse0
❑ Real RoPeNY � ��N� " "'
ae, .3
wLnecm�nryi vmairarinyosmaa Fwsu,s
far arte
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20 20 _ 20 20 _ 20 20 _ 20 _
SigreIIrte W CantyAUd�tor Caunry Date (rtnr�th. daY. Y��
C �
I/ We certfy uMer ihe penalry ot peryury Ne above a oregoing infortnalion is We and cortect arW that the applinnt is a residerrt of Intliana aM
trad buyer of the afixemen � eA property on ate application is filed.
�� (o �\ \\ � oac� c,�o.�m. a�Y ,ean
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�FiA resdent adOmss of appfitant (number aM street rnY sta�e, entl ZIP ootle)
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Date (rtronth. day 3��
person (numberaM street dry. sb(e. arq ZIP aotle)
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