HomeMy WebLinkAboutMortgage_Clore^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun hip Year
__„ = FOR DEDUCTION FROM ASSESSED VALUATION
• State FOrtn i3709 (R71 / fi09)
�' PresaiDetl by Depanment of Wral Govemment Fnance
�«.
File Mark
�STRUCTIONS:
Fwm e
To 6e filed in person of by mail wiN the County Auditor or Counry RecoNer of �he wunty where the properry is located.
Fifing Dates: i) Real Pmperty: Must file during the year for which the deduction is sought �. hiG.���aQ itpr
2) MobDe / Manulactured Homes rrof assessed as Real Prnperty Must file dudng the twelve (12) months � l� l-\
befora Ma/ch 31 0( each year the deduction is sougAt. ❑ Counry-RECVrder
See 2verse side for additional insfructnons arnl qualifications.
f vaLe d real paperty as W
aaRJtl yP2f
If ra, what is his / her e� share of interest?
If name m rem�d
rtnrtgagee b mntrac� seAer
�=i�J �o a- oo/ �
Mortpape / Contrau 4dehtedness unpad as o(
Mam}� t, artent yeer
Addres of � w cantrad srder (numbrf and stree4 �1: stafefaM LP oo0e)
Nartre of atsi�ee or athu mvner or hdder M mortga9e / �n/'y
(:�L
AAdren at asti9nee (num0ei aM street, ray. state, and LP cotle)
Does applitant wm pmperty in any aNer If yes, what munt�?
munry in Ind'ana? I-1 ..__ I-1 .�_
E'i�]
��
amount of.
�- o
uWebtedrress
wro� ia�vng u6mai_ . _. �
20 _ � 20 _ � 20 _ � 20 _
spouse,
. �
V /� /OJ ��
as d Is Ne epplaant Me sde
� legal p equila6le amM
❑ Yes ❑ No
wtth wtwm
property in Quesfion: Mnuelty Assessed
ea� PropeAy � Q am�any nssessed
�ao�a� ..
Dra�i�e'r NO•�• :.............
Card N�• ...! � �. �:....
�.?�� al��'� _
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I/ We certify undu ihe penalry of perjury ttiat Ne above and foregoing infortnation is true and corte�Y and that the apptinnt is a resident ot Indiare aM
amer I contrad buyer of the afinementioned property on date appiication is filed.
�raniminwwrt RiO.ume1_ _ l� � (�. �Y.l�n
� Full resident eddress ot a�rani (number and shee4 aN, �te, antl ZfP e)
O— 7`�S S % r'' .-L/V L <
Person auNOiaed Ey dWy exetvted Powet o(Atlomey rn by IC 67.7-12�.7 � Date (/nonW. daY• Yea�
Address of authn'ved pereon (number aM sbeet, dry. state. erM ZIP code) . .. _' _