HomeMy WebLinkAboutMortgage_IversonDULY ENTERED FOR
"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES3ub ect �' ac e
+ FOR DEDUCTION FROM ASSESSED VALUATION day of
• State Fortn d3709 (R17 / 6-09)
S � Prewibed by DeP��nl of Loral Covemmerit F�nce
� � File
wsraucnoNS:
To 6e filed in rson w 6 mai/ wiN fhe Coun Auditor or Coun Recorder of the coun whe2 the rDpe �
Fil'ng Dates: � Real Property: Must fi!e dun� Ne yea� for whfch the deductlon is mught P YdfCe�s�ocated.
2J Mobde /Manulactumd Homes iat assessed as Real Property Must file during the hveHe (12) monfhs �
be(ore March 31 0! each year the deduction is sought.
See reverse side for additional insWU6ons arM qualifiratioi}s. /y� n � z_.�� ..;�
Ta "ng i Keynumber/kgaldesaiption
� a -��-��- 3- o
A�sed vd4ie cQ real yoperty as Mor[gage / CanbaG Gdebtetlness unpaid as of
MarM t. qrmtl year Mert�h 1, arte /ye�e� / ' /
� / / � 7 b �
Ii ra, what Is his / her e�mU stiare ot interest? It awm
If narne on remrd is dAterrst tAan Mat of aDpbcant, mCirate helw•^.
Name ot rtnrt9a9ee ar mnbaU uller r/ ��
l
Address of rtaRga9ee or mntract seller (number aM sveef, ciry, sbte, arM
�.Wm¢ of atignee w oNU owner w hdder of mMgage
AdE255 of assignee (number aM stree; tlry, state, and ZIP code)
Dces epplicam rnm poperty in any o�hu If yes, what counry
�^�'�^i�w�a^aa n „__ n .,_
ot.
~�i��
�
Mar�uditor
Coun fwditnr
County Recorder
Yes L1 No
with someone other than spouse. iMimte wdh wtfom�
I5 Me pmperry in qurstion: Mnua�y Assessed
�Real Property Q MnuallyAsse55ed
Mobile Hart�e (IC 6
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D�•a�ver i\�0...�.�D�
� ............ �
� o�
Cal'[I 1�`O. ....°2 ��a.
COUNTY AUf � � " "
�n,ay�.�, ...... _
20 _ 2b _ 20 _ 20 _ 20 _ 20 _ 20
Signaqrte of Caunb Aud'rtnr Counry Date (month. daY YT��
I I We certify uMer Ihe penalry o( perjury that Ne aDOVe arW foregoing infortnalion is We and mrrect arM ihat the applinnt is a resident of Indiara ark
owner I mntracl buyer ot the a(o2melrtioned property on date application is filed.
Sianatuee (owne/s hN namB) ,. n . . Date (monfi. eaY. Y�e�
ard ZrIP'm
" •
Person autharized Dy tluty execueed Pv«er of Attorney or by IC Fl.t-12-0.7 I Daee (monN, day, yea�
Address of authorrseA person (number and snee; cily. state, antl LP catle) .
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