HomeMy WebLinkAboutMortgage_Douglas (5)ry� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
__ _ FOR DEDUCTION FROM ASSESSED VALUATION
� Sfate Fwm 43709 (R71 / 6-09) �� �\
�• i PresaibeE by DeparvreM a( Lo�l Govemrtrent Frence �
µ File Mark
NSTRUCTIONS: �Q
To 6e fiied in person a by mail with Ihe CountyAUditor or Counry Recorder o/ the county whe2 Ihe property.is located. F� ��'
Filing Dates: i) Real Property: Must file durirg the year for which the deducLOn is sought � �uniy Auditor
2) Mob�7e /Manulactured Homes rat assessed as Real Property: Must file dunng fhe fwelve (72) months
6efore March 31 oleach year the deduction is soughG ❑ Cou^tY Recorder
See reverse side !or addilional instnictbns and Qualificafions.
AppGrant(o orcaptrartbuyey-�seeresficeonypnraversesiA�,]� (� „
_,x.�„�,_
Asessed vaLe d real qa�peny as
Matr}i 1. aarent year
It m. what a h'a
If rwne on recwy js Qif(erent Nan Ihat ot aoP��t �dirate EeWw
Name oi rtmrt�agee or mntraq seller
w contrad
awner or ndaer ot mortgage
MCress of assgnee (numDer arM sveef, c4y. slate,
Does appircant oxn pfoperty in any oNer
countyinlntlana?
❑ Yes ❑ No
�-000.��a-Das I ��"�������
indehtetlness unpaid az U Mongege I Cantracl cWeMedfmss unpaid az o( Is M�
�r.� aate of aOP�� kgal
city. sfale. aM ZIP code)
If yes. what munt�?
K owned wiN someorie alher Ihan spouu, iMkate whh wFart�
ant tl�e sde
�ilade awneR
Yes ❑ No
k Me P�G�Y in VuesUan: MnuaOy A55e55ed
❑ Rea� Ror�ro ❑ ��r�
(or wnm� yeaR
m property
� COUNTY AUDROR
Deduction approved'm ihe amount oY.
20 20 20 20 _ 20 _ 2q _ ZO
SignaW2 W Camb Audvm Counry oate (rtrmth. daY. Yea�)
i/ We certHy under the penalry of perjury tliat Ihe above and foregoing informalion is We and cortect and ihat Ne applitant is a resident of IrWiana and
owner / mnVacY 6uyer of the afwemenlioned property on date applicatlon is filed.
Signanue (owrreYS !W nartre) Date (rmitl�. day. Yea�
Full resitlent address of applicant (numDer and SbeeS �; ��e. a�W ZIP code)
Person auNa¢eE Oy Culy exearted Power of Httortiey w by IC Gt.t-12-0.7 Date (mmN. Jay, yea�
AdEress of autl�orvcd person (numOer amd stree4 �1R sbte, antl LP mtle)