HomeMy WebLinkAboutMortgage_Burgess (3)� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
__ , FOR DEDUCTION FROM ASSESSED VALUATION
:. State Fwm 43709 (R71 / 6O9)
�' ,,,. Presaibetl M DePaNneM o( Laal Govemmard Ftrarce
INSTRUCTIONS:
b De filed in person or by mail wifh the CountyAuditor or Counry Reco/der o/ the counry whe�e the property is located.
Fitirg Dates: 1) Real Property: Must file during the year for which tha deduction is sought.
2) Mo6Ae / ManNadu2d hbmes rat assessed as Real Prope/1y: Must file dunng fhe hveNe (12) monfhs
before Maich 3yo( each yenr the deduction is mught.
/
Sea reverse side Jor ad6ttionel insVUCUons arM oualifications. .-.
County Remrder
Y
T KeY i kgai AesrnGhon / 1 Retwd n� Fage �
� _ -3 1-�Foo -oo , /�-0d/ i
rWue d p�ope�ty as of ge I Cantraa inde6tetlness unpaid as ot Mortgaga / Conttxt iMebtednass unpalE as d Is ihe eppfrcanl Na sde
MertA 1. ta�rt yrar 1. w Eate af appGratnn legal or equilade oMneYi
�n�� O(�� ❑ Yes ❑ No
tt ro. what is his I tref euU share ot intuest? It owrred with sdneone othar Ihan spouse. indl�fe wtrh v.liom
It nartre m iemtl a dAfemnt Ihan Nat o! appOCant h�d'vate �ebrl Is C�e properiy in Question: MnuaOy As.cesseE
i � ❑ Real Ropetty ❑ Mnually Psessed .'_
Name W rtiortgagea or
or contrad sr�er (num6e� erd stree; rdY. 5ate,
w Imider ot mrtgaga
(numbr! arM sLee4 �N', slafe. entl LP mde)
Daes ePp6rant wm p�openy in any other
muNy in IMia�u? rl ..' _
Dra�� er �\'O...a� I l�
�_ ...............
�� c��-� �ro. ..... �a3 �
.......�.
�,—W �-�I, c� ...
owner / contraa buyer �� ��.. _._..
nawre (owner�t lutl reme) �
/l. � Ai I / %% . _. _ . .
resitlent eEdres of zpprxant (numDe� D t, rury, .yf�e. antl ZIP m
� �/a S / u: V
mn aulM�ved Dy Outy �earted Pwer of Attorncy w by IC 61.7-12-0.7
Ge�^ (num0er arM sbeeG �dY. sfate. aM
What Teriig
zo— � zo—
ror wrrem reaR
20 _
:IW an p�opGty
Yes ❑ No
�� ��. �Y ��
20 _
ing infwmaUon is true and correct arM Mat ihe applirant is a resident ot IMiana and
ication is filed.
Date Qrnndi, dey, yaer)
'�- �. - / (7