HomeMy WebLinkAboutMortgage_Basham�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
_. FOR DEDUCTION FROM ASSESSED VALUATION
� Stata Fortn 43709 (R11 / 6-09)
�,.,. Prrsfiibed Ey Departmetd at Lad GaremmeM Fuunce
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wsrnucnoNS:
Form l�ed wiN:
To be hled in person w by mail witA the CountyAuditor or Counry Recorder o/ fhe county where the property is bcated. 1
FiHrg Dates: 1) Real Property: Must file durny Ne year (or which fhe deducLOn is soughc Q C 1 2 �nly Auditw
2) Mo6de / Manufaduied Homes not assessed as Real Prt�perty: Must file dunng Me tweHe (12) monNs
6eRZe Ma�cA 37 oleach year Ne deduUion is sougM. ❑ County Recorder
See ieverse side (or additional �tnations and qualiFiyetlrn{s.
li no. wlvl6 NS / 1�¢f ¢�tl
If nama at lemfd 4 LHtda
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umn chat ot appaant, uWicate celaw
Nartre of mortga9ee ar ern�traG aeAer
Add�ea of nwrq� a mntratl se�er (nunber ard so
Name W azvryxe a Wws avmer or halder af mort9age
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2p T � 20 - � 20
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- � -Dad. �-75-Od8 � C'� P��fo�F3
n� unpaid az o/ Mortgage / ConYaci'uMeMeOness un0aitl as d Is Me aPOfirant tla sde
C} data of a7P�� � a �� �
! DO ❑ Yes ❑ No
tf ovmed with someore other ihan spase. ud'�te Wth whom
Is Ne P�DertY in 7ues0an: MmiaM Assessed
❑ Real afoaertv ❑ MnuaMAss�sed . . _
stem. aM LP mde)
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[a.i�r;i.- •m_ i.7►t.1:�
za
0
Nas Na deduction Eeen rc9uested m O�Oe+H
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zo_ � zo_ � p
ot itor Counry Dete (month. tlay 1�n�1_/ O
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/ We " unCU N n Iry ot perjury iha above aM foregoing infortnation is true end cortect arM that Ne applipnt is a residertt of IrWiana arW
owner I ntract r Ne aforemention pr perty on date application is filed.
ownerY rm ) Date (nnnN, daY. Yaa�
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�rrsitle�rt atldrea d a t( ber antl L(bY, sta%e. entl LP cotle)
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Prisan autlraaeE by G!y GceryteG of AtbmeY a by IC 61.1-12-0.7 Date (/rromh. Oa1: }ea�
ACtlresv of auNw'ved pemm (numbaraib sbee; dry, sfele. an0 ZIP wde) .
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