HomeMy WebLinkAboutMortgage_Briggs"'n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun sh' ar
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FOR DEDUCTION FROM ASSESSED VALUATION
• State Fortn 43709 (R11 / 6-09)
S I PrewibeA �y DePartrt�eM a( Laal Gwemmerd Fuarce
� ' File Mark
�NSTRUCTIONS:
F ed vnN:
To be (led in person w by mail with the CountyAuditw or Counry Recorder of fhe county where [he property is located.
Fil"mg Da[es: 7) Real Pmperty: Must !le durnrg the year (or which the deductlon is saught C� ditnr
2J Mo6de / ManuFactured Homes rat assessed as Real Property Must file durirg the hvelve (12) montAs
befora MarCh 31 of each year the deduction is sotght. ❑ � �
See reverse side /or additional instructions and qualifications. G I B
npp5�am (owner ormnvact 6uye�- see restrirllms ryryeverse side)
Assessed va4re of � paperty
�Ia�U 1, acmnt yrar
If rw. �Mat IS lus l h.v eraC
Key �wm6er / legal desdtpl6n
_a vuZO3-cb3 'Yo /-oa
�Mortgage / Contraa in0e6teAness unpaid as of Mortgage I�
Martli 1, curreM yPar date ot a0d
% � .�QQ
If narne on 2md is ddterent Nan that o( a001kanl ifWirate beqw:
Nartre of rt�ortgagee or mntrad se9er
Address of rrort9agce or mntrad seDer (numDe� antl stree(. clly, sfete,
Name of assignee w other owner or hdder of morigage
AdCress ot assignee (num6eraM s0ee(, ary. 57ate, and ZIP m0e)
Dces applimm wm poperty in any oNer
counry m Intlara? ❑ Yes
�
Deaumon apprwed m Ihe amount of
20 20 _
If yes,
�
cord rwmba Page num0er
ao � 5 s
�aid as d Is Ne epp�xant Ne sole
�egal w equita6le o�v�(1
❑ Yes ❑ No
tt awried wiN wrtiewre otMl ihan sP�+�. indxa[e witli whom
perty in QuesGOn: MnuaM Assessed
arocertv �i�nn�a�Nass�
Drawer •\0...°10 � I .........
� Sa55
C�CC� �� . .....................
� 7�� 500• �
COUNTYAUDITOR �
20 � 20 _
Counry
20
Date (mavh. Eay.
�,P�
Yes ❑ No
Pi�]
I/ We certify urWer Ne penalry o( perjury that Ne above aM foregoing informalion is We and cortect and Mat Ne appiicant is a resident of IMiana and
owner! contract buyer of Ne aforementioned property on date applicatlon is filed.
SignaWre (owneh fiAI name) /, � A /i ' Date (month. daY. lea�
F�A
by duty ezecutetl Power of Attomey or Cy IC 6L742-0.
person (numberantl street, ci(y. 5tafe. an0 LP cnde)
Date (month, day, Yva�