HomeMy WebLinkAboutMortgage_Crisp^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
:._—
= FOR DEDUCTION FROM ASSESSED VALUATION
� 51ate Fwm 63709 (R71 / 6-09)
�,,,� j PresaibeE by DepanmeM of Lxal GovemmeN Firunce
ile Mark
�STRUCTIONS:
6e lled in person w by mail with Ne CouniyAWitw or Counry Recorder of the counry where the property is located.
Filirg Dates: 7) Real PropeRy: Must �le dun�g the yearlor whicA fhe deduclion is sought.
2J Mo6ile /Manulectu2d Homes irot assesced as Real Property Must hle dunrg the hveNe (12J months
bePore March 37 of each year the deduclion is sought.
See reverse side /or addiGOnel instnictions and qualifications.
AoMrcantlownerarmntradbuve/-see25nictqnson2versesdel .. _ . �
o�U�� . �
Tabng District n - Key
y.d:,,a,.-.o% ' a
n�sm � �r � �y as m
Ala�rh 1, cim�rt year
It no. what fs his / her e�cl shara o1 intere
I( name on record is Eiflerent Nan Nat of a
Recorder
r/ legal tlesaiptldn / � RecoN number Page mim0er
-18- 3- 0 3-000. 3� - o a 6 o a d a-�F
Mortgage / Contrac[ indebtedn¢ss unpaid as of Mwtgage I Contrect uMe6tedrress �mpaiE as d Is Ne eppfiont Ne =^'°
Mamh 1, arte�rt year o date of appGCation legal or cquita6le bvnreh
74 Q4 o nYes ❑No
Name af rtartgagee ar conVaG seller �/�
Atldress d matgagee or contraG seDer (nurtib� aM streel, fny, state, aM ZIP code)
Name at assignee or otha wmer rn MIAer M nwrt[
A4dress of asszgiee (num0er and snee4 dry. s+ete,
Dces eppli�ant wm pmperry in any oNu
muMy in IMaru? ❑ Y2s
❑ No
I
Detlucfirn �pwed'o� Ihe amoum ot -
wrtieone oNer Nan spouse,
Is Ihe property in Question: Mnuelly Assessed
�ieal Pfoperty ❑ AfIflUalyA�seSSed
Modle Fiome IIC 61.
u� cwe�
Drativer i\r
O. �Z, o /. /. -
I( y�s. wfiat munry? W�a17ari^9 Disbi[ ......
Cal'd �\`O. ..,•�2 2 y
COUNTY AUDROR � � ' ' ' • • • • . . ,
20 _ � 20 � 20 � 2� _ � 20 I 20 � 20
Sig�ature d CamN AuOitor Gouny oate lrtmm. daY. Y��
c . -r. - — _
1/ We certify under the penalry of ury that Ne a antl foregoing in(ortnatlm is We and cortect arM that Ne applirant is a resideM of Indana aM
owner I contraq buyer o( Ne aforementioned pmpe on da[e appliralion is filed.
' �ature (awneh MI me) � Date (mor�N. daY. Yaa�)
r �
F� ' ent o(a " t(numbe stree(, ciry, state, ZlPOOtle)
� � . � . f� . �� �. .
Person autlqi¢etl Oy EWy exewted Paxer of Aftomey rn by IC 61.1112-0. Date (rtqnN, Gay, yEa�
Mtlress o! aulhorrzetl persm (numberaiM sveet ciry. state, an0 ZIP code) .