HomeMy WebLinkAboutMortgage_Lane"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coum
_. FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R71 / 6-09)
� PresaiEeE M�P��M of Lo� GovemmeM Fuance '
�«.
INSTRUCTIONS:
To be lled in person or Dy mail with the CounryAUdita or County Recorder o/ the counry where the pioperty is located:
Fitirg Da[es: 1i Real Property: Must file dunng the year (or which tha deduction is sought.
2) Mob�7e / Manulactuled Homes iwt assessed as Real Pmperty Must file dunng the hveAre (72) months
befae March 31 of each year Ne deduction is swght.
See 2verse side (or addtionel instrtictions and qualdxations.
qaperty as at Mwtpag e/ Contraa u
Mem}i t, artent yrar
i 110. Whdl l5 hISI hG 0i2t1 Sh8l0 O( Y11LT¢Si?
H nane m recad "s &ItrJait Nan ihat d app6ran; IMkate Eebvr.
r�ame m nw�a�e « mm�aa une,
Addres of moN9agce v oontrac� sW
owner or halder of mortgage
cRy, s�te, aM ZIP
AEOress oi assignee (num0ar arb saee4 �: stE�e. ar�a ur coae�
Dces epp�H o.m M�P�Y N e�Y otl,e, ��,�, wh�
munry in Ind"ana? I"I .._ _ i"I .._
Deduaon app�weC In tl�e
Year
,� COUnry Auditnr
❑ Coun.xt'i3g,1D
RemN numbc Page
�_a � �a a��
1 as of MMgage I Contraa iridebteA�wss unpaiE as d Is Ne appOrant tlre sde
Eate o( ap legal ar epuitaHe ame(.�
�� � ❑ Yes ❑ No
It cMneC wiN san�e othm ihan sCwue. ind'�te wIM whom
GOUNTYAUDROR
Is ObOP�Y in Question: MmiePy AssesseC
Re� �oPeny ❑ amuany w�a
a�on�� � nc s
ID.........
Dra�ver NO. Q..
ay30 ..
Card \O. ........... ....
� 15��0�.`Q/ �����
2p_ 2tl_ 20 20_ 20_ 2b_ 20_
Si9naMe N Camb Aueita Counry Date (monM. daY Y��
1/ We certify unCer the penalty of perjury that Ne above arW foregoing infortnalirn is We and correct ark that the applirant is a resident of Irdiana and
owner / contract buyer ot the afo2mentioned property w� date application is filed.
��n,�:�wne/s 1un neme) oate (rtnntli. dar. YBaA
1\. .� � . � r. . ,. .--- -
FiID�¢tide�rt
Dy Ouly executeE Fower of Aitomey a by IC�6 7.7-12-0.7
eed persm (number and stree; ciry, sla�e. eM LP mde)
Date (manfh. daY Y��
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