HomeMy WebLinkAboutMortgage_Burnor1 "'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmshi r
__ ; FOR DEDUCTION FROM ASSESSED VALUATION
Slate Fwm 43709 (R11 f fi-09)
S f Pfesaibed by DeP��ra af Lool GovemnreM Fuance
File Mark
INSTRUCTIONS:
To be filed in person w by mail with the CounryAUditor or Couny Remrder of the county where the properry is located. '
FiI'mg Dates: 1) Real Property Must fde durirg the year /or which tha deducfion is sought. Counry Auditor
2) Mobde / Manufacfured Homes not assessed as Real Property Must file dunng the (welve (72J months ,�?��
be(ae March 31 0( each year the deduction is sought. caG er
Seereverseside7oradd"mm�alinstructionsarMqual�cations. GIBS H
nt(ownararcontrartbuyer-seerpyr1�qyq reverseside)
� " " � .// / / I n. V . . i )
T� ' Key rvmiCe// legal aewiptian '
a6-/8-� - o -Ooa. aQd -o�t
Assessed vahie dreal pmperly es of Abrtga9e/ Contract'udehtedness unpai0 az ot Morigage / Conrm
MeRh 1. wmntyear Mart�h 1. arrem yeer a. } G!O � date of apPfifaWn
�,
If rq, whet a his I her erx] share of interesi? If ovmetl wiM someone ott�e
tt nartie m mmtl'a diftuent Ihan ihat ol appOwrt, IMirate below:
6T?1TI
Mdress o1 mortgagee ar contract seller
Name af assignee or athr! ovmer or hdder of morigage
AECress ot assignee (numbar entl stree; tlly. stafe.
�^F�P�Y
Deduction aPW�'4 in the amount oE
zo _ � zo � zo
�y, s�/, arid LP code
code)
s, what count)?
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�zo
What Ta�drg D'stri�?
�
� Rem(d number Page numbrf
! inOeMedness unpaiA as o( Is Ne applrcant Ihe sde
kgal or equitable mmel.�
❑ Yes ❑ No
� than spouse. ind'xate with xirom
6 ihe P�Pert1' in Ouestion: MnuaDy AssesseG
❑ Real ProPertY ❑ ���Y �
Modle Fiort�e QC 61.1-i
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c�,�� ��jo. .... �5 � 3
$ �ab, ieo�...........
� c�. �r. r��
I I We certify under penalty o( perjury N Ne a6ove and foregoing intortnatlon is We and cortecl arW that the appiitant is a resideni of IrWiana arxf
ef/ contracl bu f the a menlion d property on date applicalion is filed.
re - r's hA '^ Date (nmth. deY• Y�A .
vU
��FW Qnt� nt( ren0� t.riry, te.andZ1P e) ( ��/ �
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ssm autharzed Ey duty ezewted Power of Attomey or �y I .t-12-0.7 �(�+�. �Y. 1'��
Address of aNhorae0 person (numGer aM sUee; ciy, sfate. entl ZIP code) .