HomeMy WebLinkAboutMortgage_Briner (2)"'r STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS o - s' Year
__ _� FOR DEDUCTION FROM ASSESSED VALUATION �
� �• State Fortn 43709 (R11 / 6-09)
�' ,•„ f Presoihed by Department of Local Govemrtrent Fnance
INSTRUCTIONS: � 1 IF �
To be filed in person or by mail with the CounryAudimr or Counry Recorder of the county where the pioperty is Iocate¢ F� �� ���
Filirg Dates: 1) Real Ploperty: Must �le dunng Ne yaar /o� which the deduction is sought. O� Counry AuCiwr
2J Mobile / Manufactured Fbmes not assessed as Real Property.� Must fi!e dunng the tweNe�� 21 onths�
be(ore March 37 o/each yearthe deduction is sought B�ON COUN y A �nry Recorder
See reverse side !or additronal insVUUions end qualfications.
Aoofrant (owner or contraaftbuver - see rashir�AAns m rererse�itle)
¢d Ydh12 d tEal �' a5 of
�. tlYIPJII jP2f
R no. what ¢ his I her exart shara
rertm m
mon�ayee «crno-aa seuer
Key rwmCer / legal desaiption
a - a-
MoRqage / CQo�ntra� t
f�/}�tL/ L/O
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Address d rtnryagee ar contract se➢er (n�mber and sLee; �y. sbm. aM ZIP code)
Name a1 asvryiee w oNei awner
Aildress ot �c�nce (num0er aM snee4 �y. s+ete,
Dces epplirant own property in any alAer
munry m Ind'ana?
❑ Yes ❑ No
Deduction appmveC in the amount oF.
20 _ � 20
SignaMe of Counry Audiur
5`i a -o
a5 at Mort9aGe / (
If yes. what muntyt �
COUNTY Al
20 20
mtwane aiher Ihan spouse,
number I Pa4e number
M Of
is Ihe P�oPertY in Oues�On: MnuaOy Assessed
�e�i a�oaem ❑ mm�,anr ass�s�
n� r� nc s
�,��� �uSr-� �
D r�� (��(
�— I �
d m propeny
20
No
I I We certify under ihe penalty of pe�ury Nat the ahove and foregoing infortnalion is We and mrtecl arW ihat ihe applinnt is a resident of IrWiana aM
owner I contracl buyer of Ne aforemeMioned property on date appiication is filed.
�,nawrq(o�mefs fiN name) Date (monM. day, yea�
�
Pelson autlror�E
tiry, vare, arm
7
pe�son �num6er arM sbeet, ciry, sYdte, enC LP code)
Date (monN, daY.