HomeMy WebLinkAboutMortgage_Urbanek^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
,_ + FOR DEDUCTION FROM ASSESSED VALUATION ��9
� • State Fortn A3709 (R71 ! 6�09) �
�' � � Presaibed by DePa���n of Wrvl Govemmerd France '�.
�"" File Mark
1STRUCTIONS: �� F� �� �:
To be Red in person or by mail wiN the CountyAudROr or Counry Recorder o! the counry where fhe property is located.
Filing Dates: 1J Real Pmperry: Must file during fhe year for which fhe deducLon is sought. � Counry Auditnr
2) Mobile /Manulactured Homes not assessed as Real Prnperty Must file dunng the fweNe (72) months
before March 31 of each year the deduction is sought. ❑ Counry Remrder
See reverse side for addilional instructions and qualifications.
qppG (mmerorcontraCb r-see reversesitle)
�rn.
�7 � �py� Keyrwmbas/legaldesaiption RemNnum6er Pagenumbr!
.����-1� �Co�19-c9,ao�-oo/. 3a'-oz� Olb 5897
Astesse�d r�ue d rea17oP�Y as of Abrtpa9e / Can6att iMe6tedness unP� az U Mw�9a9e / ContraY @debtedrress �mpaid as af Is Ne ePP�t the mk I
M�U �, nnW year March 7, wrtent year dafe of appfmation �� a eW�e �� '�.
6 h6 / h¢! CIMI Shaz¢ Oi If11¢l251?
If �wrie on 2cortl 5 dfierrnt lhan Nat
Name of rtrongagee or contracA
�SO�� ❑Yes ❑ No
H owneE with wrreme oiher C�an spouse. iridimte with Mrnn
bebw. Is Cie P��GQ�Y in OuesUOn: Mnua�Y AssesxE
❑ Real ProP�KY ❑ �^��Y �
Mob�e Flwne (IC 61.1-�
Addres of morc9a9ee w mntraG se�er (num6e� end svaeL �Y. s7sM.
Name of assignee or oticer owner w MIAer of morigaga
assig�e (number aM atreet �N: �le,
Dces aPW��t own property in any
counry in Irqiana? n .,_'
DeducCOn apwoved'o� the amount ot
�'R.7
res..w,ac m�nry7
vma� raA�y o
Dra�}�er iYO..°�p� b --_
Ca rd i\'Q ��?
_ � `1(0�7� cN ....... _
20 _ 20 _ 20 _ 20 20 20 _ 20 _
Sigiawre af Counry Audimr Caunry Date (monlh, EaY• Yza�)
� --r
I/ We certNy under �he penalry oi perjury that Ne arW foregoing intortnation is We and mrteU aM that the appiirant is a resident of IMiana aM
owner I tontract buyer e atorementloned property on date application is filed.
� Sipfah�re (awne/s hill me) _ ^�'' `C'�( / • Date (month. daY• Yaa�)
�.— %N/
resitlent addrass
u�
sLeet dry, stare.
Poner af Atiwney m by
aWmr'ved persa� (num0er aM sbeeC dry, stale. antl ZIP code)
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