HomeMy WebLinkAboutMortgage_Bersagliary� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
, FOR DEDUCTION FROM ASSESSED VALUATION
State Fotm 437091R11 / 6-09)
�,,,, f Presaibad by Department ol Lucal Govemrtrent Finance
roc�ka I Fii
INSTRUCTIONS:
To 6e lled in person w by mad wiN the CountyAUditor or Counry RecoNer ol the county where fhe property is �
Fitirg Dates: 1) Real Property: Must file during the year lor which the deducGon is soughL � County Auditor
2) Mo6de / Manufactured Homes rrot assessed as Real Pioperty: Must file dunng Ihe fweNe (72) monfhs MA
6etore March 31 0l each year the deduction is sroughL � C 3❑ 2 uTlunty Recorder
See reverse side for adtlitiunal instruclions and qualifications.
I Mv��l (` contrart bl / 1 V �/YL.LISL> e� � dX 1 A �
1 KY� J d(0 I—
Assessed ralue d real property as d
Mamh 1, fia`atl ytlr
If ro. whal Fs tus I her c�] sham Of Nter
Ii name on remN is Cifle1¢nt lhan ihal ol
Name af mwcgagee a mntrar� seAer
�, Q � d�;o�, — 03 . ��o -o a� "." ���, .,�
Mor�qage / ContraG indebcetl�ss unpaid az U Mongage / ConvafY irMehtedness unpaid as o( Is Ne eppGOnt Me sok
Marrh 1. rtent yePr Eate of aDP��^ legal or equBade owrreY/
��I� QQI nY� ❑No
6elow.
AAtlress of nfwtgagce u contraG seller (nurtiber end stree4 ury. stale� arN ZIP code)
Name ol assgnea or other wmer w holGer of rtprtgage
Atltlress of asv9nee (number aM sveet �itY, slafe, antl
Does applinnt wm pmperty in any oNer I If yes, W
counry in InOiana?
❑ Yes ❑ No
Dr�uCOOn apywed in Ihe amounl of:
20 � 20 � 20
W Cmmb ��r
I/ We certiy under the penalry of perjury Ihat the above
owner! mntrad buyer of the afo2mentioned property9
M
sCee4 �Y,
or
spouse.
Is ihe property in puestion: MnuaDy Assessed
� Real PtuPertY ❑ ����h�
M1bWle Fiome (IC 6
� 1 �,Q,� �/ �X O
e
�
aoo4- g8 3
� �a�,g�le bo
AdCress of authwaed persa� (number aiM sbee; dty, slate, antl LP oode)
�
tim Eeen requested on proputy
�
❑ Yes ❑ No
20
nMfh, daY Y��
! is a resident of IrMiana aM
nivh, day, yea�
,
Oate (monfh, Gay, yea�