HomeMy WebLinkAboutMortgage_Keen"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship Year
_, : FOR DEDUCTION FROM ASSESSED VALUATION
� State Fortn d3709 (R71 / 6-09) .
�,.,. � PresaiOeE M DeparlrneN M lnfal Goverrinrenl flrenca
File Mark
lNSTRUCTIONS:
To be filed in person w 6y mad wiN the CountyAUditor or Counry Recorder o! the wunry wFiere tAe property is bcated. F '9 ���
FiHrg Dates: i) Real Pmperty: Must file durrrg the year Por w/lich the deduction is sougAt. � County Auditor
2) Mobde / Manufaclured Homes lat assessed as Real Property: Must fiie during the twehre (12) moriths t7l�
6efore March 31 of each year Ne deduction is mught. �L=i ��
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See reverse side !or additionaf instnictions arM qualifications. 7 GI N COI ir,�rv .;,...__ _
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As�sed rdpie rd � popsty a af ' Mo�aga! Contraa intlrbteE�ress unpaid az W
Marft� 1. am�tl �ear Martl� 7. n�rtent yrar
n 110. N'�N� 6 WS ��12f EXdf2 Si1812 Oi Vl(P,RSl7
lilldfflBIXl !L`mItl 6 SfROfHlf N3t1 tlldl O( 27P�f:dlll. hMlCdtB b¢IOVl.
IJame o1 rmtgagee or m�o-aa se�er
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Pddress of nnrtga9ee or mntratl sWer Num6� end street �. a. . eM
Name of asignee a dhrl wmu w hddu N rt�origa9e
ACtlrPSS of asvgnee (rcmiLer arM atree; ay, stafe, and LP mtle)
Dces epplirvnt avm 0�7�Y in arry dhc H yes. what mumy
munry m Ind�ana? .n. Yes _.❑ No
— Dra�ver NO. °����
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OMTIPl� WI(11
COUNTY AUDITOR
Gl?�°P
Recortl numbc
i �/O
IrMeMed�ss unGaid as d
Yes L� No
IS OM D�PertY IIl G11PSbqf1: Mf W3�Y ASS
� R� �a�m � � �
Has Iha deduCan Eeen re9ursted m property
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- Card i\io. a3� y zo zo zo_ zo_
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`� f y0; 0�, .°` �,,,�� Date (rtmth. daY. Y��
I I We certify urWer the penalry of perjury Nat the ahove ana toregoing information is W e and cortect arW Nat the applirant is a resident of IMiana and
owner I contracl buyer of the aForemerrtioned property on date applicalion is filed.
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� FID rddent adEress of appfrant (numbe ntl sLee; tiry, state. antl P code)
P¢r�„pn autho��d Oy dWy mecuted Porer otAttomeY or Cy IL 61.1-12�.7 (
Rddress of aW�a'¢etl prlwn (num0er antl streal, dry, sbte, and LP code) "
Date (rnorW. daY.Yeah
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Date (rnonlh. da1: Y��
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