HomeMy WebLinkAboutMortgage_Blume"�n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
__,_ + POR DEDUCTION FROM ASSESSED VALUATION
� State Fortn 43709 (R71 / 6-09)
�' ,�,� PresaibeE by DepartmeM of L.aml GovemmeM Fuance
File Mark
srRUCnoNS:
befiiedin DEC Fo iN:
person or by mail with the CountyAuditor or Counry Recader of the tounry wheie the property is bcated.
Filing Dates: 1) Real Pmperty: Must file dunng the year for whicA Me deduction is soughL C� � Counry Auditor
2) Mo6ile / ManufaUUred Homes not assessed as Real Property Must file dunng Me tweHe (12) monfhs
before MaicA 31 of each year fhe deducfion is sought. unty Remrdu
See reverse side !or additional instnxtions and qualificafions. G I BSON C OU
AppGnn rorcoritractbuyer-seere;¢ictlonsmreversesiie)
7a3i(g OiStrij n KeY rwmber / legal� 3 Yo y_ o 0 0. � i/ - v a 6 � mber P�a, O
-u t- i••, �
o �� � «���
Atgessed vahle d mal qoperty az W Mortgage / Contract indeMetlnass unpaid as of Mortgage / Conttx[ "vitleMetlnrss unpaitl as d Is Ne eppfifant the sde
Marh 1. ammt year Ma�ch 1, wrteM yeer tla[e af apP�m� legal or eQUitable oxme(?
� ❑ Yes ❑ No
11 no. �Mal's his / her exafi share of interesl? If mied wiM someorre ather than spouse. irvficate with whom
J�TL �
ol mwt�3Jee or ContraU SeAer
Pddress of rtiwtgagee or contratl seAer
Name af assi�ee w othrl owner or
AECresS
avWcant, iriairare bebrr.
state,
sfafe, andZlPCOtle)
Dces epplkant own popeny in any oMer �� If yes, whal muny.+
counry in Indena? ❑ No
❑ Yes
Dedutrion aPWOVed m Ihe atroun
20 _ 20
$ig�aNre o( Caunry Audilor
r ��
�
)UNTY AUDI
20
Caunry
Is ihe properry in QuesUan: Mnua�y As5es5eG
[�Real ProPertY ❑ M^ualy Psse�d
MoWle Hane QC 6
au,m�. , R°"� A�� �"'
❑ No
��_�303 _
�1 � p—
Daie (rtbNh. daY Y��
FI7
I/ We certify under the penally �/perjury that Ih above and foregoing infortnalion is We and cortect arW ihat the applipnt is a resitlent o( IMiare antl
owner / contracl buyer of �he aforemention operty on date appliption is filed. �
SignaNre s Iu0 ) Date (norRh. daY• Yaa�)
X
F� b ea�aS`��Sim �^�� k�e �Pa�+�'�i �� 76�,'d�
Person auNOra� Dy CWy eaecuted Power o( AttorneY m M IC 67.1-12-0.7 Date (monN. day, yca�
Pddress of auNa¢ed person (num6er and street, dry. state.