HomeMy WebLinkAboutMortgage_Davis (29)^�+ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
_, • FOR DEDUCTION FROM ASSESSED VALUATION
• Sfate Fortn C3709 (R71 / 6-W )
�,w I Presvibetl by �epartrtrenl of Local Govemment Ffpnce
INSTRUCTIONS:
To 6e filed in person or by mail with the CountyAUdifor or Counry Recorder o/ the county where the property is located.
Filirg Dates: 1) Real Property: Must file dunrx� the year for which the deducfion is sought.
2J Mo6ile / Manufactured Homes irot assessed as Real Pmperty: Must h7e dunng tAe tweHe (72J months
before March 37 0l each yea� the deduction is sought.
See reverse side /w addifiona! instrt�ctlons and qualificafions.
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Assesse7 vaWe d real WopenY az W Mor�qa9e / Contrarl u
MaRh 1. atmv ym Mamh 1. arrent yeer
If m, what is his / her exar� share o� �nterest?
It nartre m remrtl's dAtemnt ihan Nat ot app6cant, iMipte bebw.
rUme m ma4iasee a rvnvaa
...,�.��• 4 ��b�� I
� Counry Au
% Remrtl nu Page numbrJ
-00% s� a� D � � �
s unpaid az of Mwtgage / ContrarY mdebtedn�s unpaiC as d is Ne app6rant the sale
tlate of app4U legal w equitatle ovmcY.+
� � ❑ Yes ❑ No
If owned with someane other than spouse,'udimte wiih wtrom
Is procertYmV�b��/�nualyASSessed
Real Hoperty ❑ ArmuaOy Asses�sed
nnoa� riome nc ��.i-�
sheet c+lY. 5am. aM ZIP code)
(numberaM sLEe4 �Y. �fe, aM Z/P mtle)
uoperty in any oNer I( yes, wh
COUNT
Za— i p— i�— i zo_
O�ULs f�G(.�J J,�.
CEl�.S1�.11.�4 `
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35 ❑
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Signanrte d Counb Autlitor caunry I oa�e lmonm. �r• r��
I I We certfy u�er Ne penalry of perjury that the above and (oreguing infom�alirn is We and cortect a`W that the applinnt is a resident of Indiana arM
owner I contraq buyer of Ne aforeme�rtioned property on date application is filed.
Siafa[ure (owne/s fidl nartre) Date (rtwW. deY. Y��1. .
�l�(11,:�ccr �CC��> � - `1- I O
Fup msiCent addiess of app�frcant (iwmbar antl shee4 aN, �te. and ZfP oode)
ChC�\`�\l(�O._ \)O.SiI`�
Pmsan aWror�E Ey duty ezecu:ed Power W Attnney or Dy IC 6t.t-t2-0.7
AdEress ot authttrsM person (numbe! aM sbce; ury, sfata. an0 LP oode)
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