HomeMy WebLinkAboutMortgage_Walther^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township vear
__ _ a FOR DEDUCTION FROM ASSESSED VALUATION
� State Fortn G3709 (R11 / 6-09)
�' 1 PresaibeA Ey DepaNnenl of Local Govemment Frerxe
� File Mark
INSTRUCTIONS:
To be (led in person or by mail wiM (he CountyAUditor or Counry Recorder o( the county where the property is located.
F7irg Dates: 7J Real Property: Mus! file dunrg fhe yrear /or whith fha deduclion is soughG Auditor
2) Mo6Be / Manulactuled Homes not assessed as Real PiopeRy: Must file dunng tAe twelve (72� months C�
befae Mamh 31 of each year the deducfion is soughG C ry er
Seereversesideforadditionalinstructionsandqualificatons. GIBS UNTYqUDIT
MP�m(ownerarcon�ct�iyer-seemstri�or�smre�.xrsesiie) n � _ ... �
Assessetl ralue af teal pfopeny a of
IM2�fl�i ac�vrt}WN
1(110, Whdt R hl5l hEf Q;2q Sh2fE Of VIfCICSt?
If �wrie m remrE a 6Rerent Nan thal of app[
tJame of rtiormaaee or cnntrxt seller
' legal tlescipti0n
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Mc�aBe / COnb2Q IME
art�h 1. a�rtenl yrsr
Pddtess of mornJa9rx «mnbaG seDU (number end stree4 �'M state. aM Z/P oodeJ
Name of assi9nee w dher owner or holder o( mortgage
ACCress ot asvgnee (number aM slreeG ctiy, slafe, and
Dces epplim(n ovm pmperty in any oNer
counryinlntlana?
❑ Yes \ o
Detluaion apprwM m tlre amount of-
m
sq�amre a co�mq nwno�
��y"j'`� ��ar�;���
Rttad num0er
1 I
unp3id as of I
IS C�e WoPMY in VueStion: Mnu211y AS5e5se0
[�ea� a'oaertv ❑ amua�y assessed
hbdle Hame fIC 6
u m. wnat counM vJhat raarr— � p ��SJ ~� �pMr
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COUNTYAUOROR
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I/ We certify urWer the penalry o( perjury Mat the above arW (oregoing infortnalion is We and correcl arW lhat Ne applicant is a residenl of Ircliana aM
owner / mntracl buyer of ihe aforementioned property on date application is filed.
7naW�(owne(s fi� reme) . � (��. �Y• Y�a�)
atldres d appGmrt (rwm6e� arM stree(, dry, state, a+d LP oode)
; F. tUalnu+ �t, ower�sv�
uvEd Dy dWy ezewted Power W Attomey or by IC G7.1-12-0.7
uthurzed person (number arM sbee{ dry, state, and ZIP wtle)
oa� c,�un. �: �