HomeMy WebLinkAboutMortgage_Chamberlain (5)"'+ STATEMENT OF MORTGAGE OR CONTRACT INDEBTE�S� C ownship vear
� FOR DEDUCTION FROM ASSESSED VALUATION
• Sbte Form d3709 (R71 / 6-09)
� j Presoibetl by Department ot Lncal Govemmerit Fuiance
JUL 1 ��° Filen4ark
INSTRUCTIONS:
Fwm (Jed
To be �led in person or by mail with the CountyAuditor or Counry Recorder of the counry where fhe pia��gy� tgd�
Filirg Dates: 7) Real Property: Must file dunrg Ne year fir which the deduction is sought ��< <V Counry Autlimr
2) Mobile /Manufactured Homes rrot assessed as Real Pmperty: Must file dudnulhelw�NefO�NTY DI OR ❑ County Recorder
before March 37 of each year the deduclion is sought. liIBS N C
See 2verse side for addilionel inshucdons arM quali�rcations. ...
npp�rcant (owner or �r1E�rt buyer �: eqyeur��ons ayr6e�r/e s:ie) /� � '
Areal p�opMty as
Y�
ro.
I1 name pf �emb o tlilterent than Nat
Nartre o1 rtnrigagea « mntract se0er
iMipte bebv`
AOCress ot rtnrtgagce or mntract seller (number aM strae; cIIy, sfete, eM
Name al assignee a oNer owner w hoNer W rtprtgage
nearess
stree4 �; s+ete,
Dces app(�nt wm pmperty in any �
tauntymindena? ❑ Yes
DeOuction approveE In Ux amount of.
20
Sig�ture of Ca�mryAWimr
20 _
No
7e / Con� rtWebtetlnrss unpaiE as o! Is Ihe
appGration legal
If owned wiM someorie othrl ttan spouse. 4Nrcate with Mtam
rita6le amel.�
Yes ❑ No
Is ihe property in GuesUOn: MnuaM Assessed
❑ Real Property ❑ MnuallyAssessed
_ _
�r�.w Dra��•er \�0.. a� .....,... ,,,°� `
Card NO. ....0.�.7%�........
�Q�,�' '��o�J,Q'�. W
20 20 I 20 _ � 20 _
1 I We certify under Ne penalry o( perjury ihat Ne
owner! contracl buyer of the aforementioned pro
sbeef,
s�ao�v�vPm
Yes ❑ No
Dale (monM. daY. Y��
20 _
anC foregoing in(ortnalion is We and mrteq and ihat the applicant is a resident of IrWiana arM
n date application is filed.
, Date (monfi, daY. Yaa�
antl ZIP code)
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