HomeMy WebLinkAboutMortgage_Chamberlain (9)STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES T ns vear
_ FOR DEDUCTION FROM ASSESSED VALUATION
Stace Form 43709 (R10 /17-08)
� � Presaibed by Depaihnent of Lor� GwemmeM Fiiurce
INSTRUCTIONS: i e MOAc
To 6e fded in person or 6y med with !he CaunlyAuditar d the covn(y where the popeRy is located. `—�.,
filirg Dates: 1J Real Property: Must Re dving the yearfw wAich Ne deduclion is sovght A��a ,C/�t,
2) Mo6de /Manulxtured Homes not assessed es Real Property: Must file dunng the fweNa[]2)nm C t�N fu�e �af"tich 310/ each yenr
thedeductionissoughL �+�tlSO UDITOF
See reverse sde /o+addRional irtstrudions and vualihcations
0
N ro. what
¢' V i
mher / legal davlqition
` -� -o - oo-�/.aoi-oa� aoo� a��5
f�eal property as d a/ Cmirap indeWednea unpaid as d Matpape / Contracl indeMednass un�eid as d Is Ihe app6�aN Ure ade
yaa . aureM yaar � dafe o( appfraEOn legal v apuGable owielt
❑ Yes ❑ No
/ her e�atl share d i�resYt If wmed with someone dher Uw� sP�sa, indimte with wAwm
If name m reard is dINerartl Ihari Ihat of auoGCant. iMCaOe belar.
Name d morigagee m mnvad setler �
Pddress d mongapee a cmlraG se0er (nun6e/and
Na�re N azsiprree or dhw owner or hddar of mptpapa
Does aVd�l orm poperty in anY dher
cwrttly in IMiarq7 ❑ YCS � No
S.L3
streel �y. slafe. and LP code)
LP mde)
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20 I 20 I 20
20
�5 YIB pfOpBl�' N QU85U011: i1MU2P/ i155855Bd
[�$eal PrwertY ❑ Mnualy Assesseo
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- Dra\\'Cr \O••••�' '
' . .
, . ,, , ��'15
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_ Card i�0•"••�'70,�'°c oNo
20 � 20 � 20
(mmM, day, yea�
I/ We certify under the penalty of perjury ihat the above and fwegoing mfortnatim is true arW correr2 and Vat the applicant is a resiGent of InOiana arW
owner / mntrad buyer o( ihe a(orementioned property on Eate application is filed.
�nalura�(aw�sfi/renre) . /1 n /l ., Dato(rtronlh.tlaY•Y�)
a
W aulhor¢ed parsan (num6er and aMeet, dty, sbfe. and LP codo)