HomeMy WebLinkAboutMortgage_Breivogel°'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS coun Township Year
:>-_.,
. FOR DEDUCTION FROM ASSESSED VALUATION
� Sfate Fortn 43709 (R11 / 609)
4' ,,,, � P�esaibetl by Depanmerd of Lxal GovemmeM Fifw¢e
�0 iVi2l�(
�vsrRUCnoNS:
b 6e filed in F� �� ��
person a by mail with fhe CountyAuditw or Counry Recorder of Ne county where fhe property is 1 ��
FRirg Dafes: 7) Real Roperty: Must file dunng the year for which the deduction is sought. ,�,n,.r�d���
2) Mo6ile / Manulactured Homes not assessed as Real Pmperty.� Must fi7e dunng the twelve (12J mo h� ���
before March 31 of eacA year Ne deduction is sought 4tllyRecorder
See leverse side for addiUOnal insWCtnons arM qualifications.
AppGCant (owne !ra�ibuyer - see on r�verse . 1�
� U� �F- !� 1. �lnrna�y � � m..-�
Tad�g Distrct ' 1 nuN
� �
Assessed raqR dreal popatY a of
MazU 7, aamnl year
If rw. whal is his l her exad share of interesl?
1! nazne on record is 6Rermt fhan lhat ot app6ce
Name of morraaaee or mntrsct se�ler
S'Wn VV[/�• (3 �� Recordnumberv enu��
�/ Contr'aR'udebte0�5s Un(giA as of Mort9a9e / Contrad'vitleM unpaid as of Ls Ne ePP�t Iha 5de
arterrt yeer Eate o/ appGt�ation legal w eQUitable a�
❑ Yes ❑ No
If owned wiN someorre other ihan spouse, indinfe wiih wham
'vidicate below
Address ot nart9a9ce or mnlrad se0er (n�mbe� and sbeel, city. state. and ZIP code)
Name at assignee w Wher awner or
AEtlress of asagnee (num6er aM stree; rdy, state,
lirvnt own ptoperty in anY o?�d
India�w?
❑ Yes
ueauaon appovea m me amoune or.
zo
Sig�ame d Ca�mb nwnor
20
._.._._..,_ ._ I.wnyre,a..,niurveo
D���,,.�,-.�o....ao� i
car� ��o. ......53�g
.......
���,���.�
Is Me P�oPertY in OuesGm: MnuaOy Assessed
❑ Rea� Poocenv ❑ ��M �
Has Ihis deCUOion Oeen reque5te0 on property
for Curten� W� r-i __ r't
� I �
yea�
i/ We�certrfy uMer the penatty of perjury that the above anE foregoing infortnalion is We and cortect and thai the applipnt is a resident of InEiana aM
owner / mntrad buyer of the afaementioned pro�erty on date applicalion is filed.
Psson auttp�aetl Ey
of applirant
antl
person (numberaMSnee;dty.slafe.andZlPmch)
Dale (monfh. tlzY, Y'�a�