HomeMy WebLinkAboutMortgage_Luebbehusen (3)^�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS T h' Year
__ _ FOR DEDUCTION FROM ASSESSED VALUATION
State Farm G3709 (R71 / 6-09)
,' w. PresaibeE by DePartmeM o(LOW Govemment FirwnCe
File ark
INSTRUCTIONS: N O 1�
t�e0 wiN:
To be filed in person w 6y mail wiN the CountyAuditor o� Counry Recorder o/ the counry wheie the prope�ly is located.
FiNrg Dates: 1) Real Pmperty: Must file dunrg the yrear for which fhe deduction is sough[. unty Auditor
2) Mobde / Manufecfured Fbmes not assessed as Real Property Musf file dunng fhe fweNe (12J marths�%. . ,a��� n R��
be(ae Maich 37 o/each year the deduction is saght. �' � �'�' �Y
See reverse side /or addNional instruct'vns arM qualfications. G I3SGh � �� ,— .,
AoofuaMlowrrerorconvad6uvar-searestrirdwasmreversesida)U . i
°l � �CQB� d6Q�bOf1
- a 3-�/ - Yoo_ 00% o�r -
AlorWape / Contran Inde6ted�ress unpaid az d Mwigage I Cor
Mamh i, curtent yeer tlate ot appGnt
�axs1
tl rwne m remrtl a C'Afereni ttun ihat of aDP��C triErcate below.
Name af rtmrtgagea n oontrarl se9er
naaress m r�a�ayee «�a,o-ac, sene�
•�,�D
sta.%.
S
ALEress of assignee (number arM sbeeS dN. state. antl LP ootle)
OT w SE _Y- o
DoeS eppli�ant ovm property in any oUU If yes, what count�!� V
munty m Indana?
❑ Yes ❑ No
���
amount
r,��
6, SD
GOUNTYAUDROR
zo _ zo _ zo _
Caunry
I I We cerlify urWer thL�penalty of perjury �(at the above and foregoing infortnation is We and cortec[ a�
owner I mntracl buyer of the aforemen�oned pfoperty on date appliption is filed.
y76
auNO�tretl by AWy ereated Power of Attcmey or by IC 67.7-12-0.7
Pdtlress of aWior�C prlson (numOeraitl sbeeS dry. sb+e,
Reto(d numbn Page wm0er �
ao� o ygo�
unP� as ot k �ha eGMcant the sde
lega� a epuilade a�meYl
❑ Yes ❑ No
spouse. irdi�fe with wlwm
Is rtx D�OenY in 7uestion: MmtaMl�ssesse0
� Real Pruperty ❑ Mlnually Assessed
�
s�ee «� w�i
Yes ❑ No
Dra�vcr \0....:�0.��,,,
Card NO. ....... `�.0 �5...
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