HomeMy WebLinkAboutMortgage_Burgess°� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R10 /11{18)
S � PrasoibetlbY�M�enidLaralGOUernmerilFinanm
INSTRUCT70NS:
To 6e filed in person or by meil with the CaurtlyAuOitor d fhe county wfrere fAe properfy is locafed.
Filirg Dates: i) Real Property: Must Poe Cunng the yeerlw which the deduc8on is sought.
2) Mobde / ManulacLired Homes not assessed as Reel PiopeAy: Must file durirg tlte tweNe (12J monlhs bel{yB�Metsh df drsaC� year
thedeductionissw�t ,)u�V G 7 tuu
See reverse sde !ar atldAional irtsUudions end 4uafficafions 1
i ouo - Kernuneerl
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Assassed vaiue dreal property as d M
Afa(ch 1. amant yaa M
Y ro. whaf is his / �er erat] share d i�re517
Y rame m record is G�Brent �han Uiat of �nt. i
Name d mongagee or cmhac� seAar /] �1
- _ /o3-DOd. �la'3-O ��
i/ Cmiracl inOebleEnea unpaid as d Matpape / Cprtrad indebtedn�
curtaM year data of a�fimtion �
Aetl(ass d mongapee ar canraa se0m (rrim6erand 4rwG �: sb1e, and LP mde)
Nama oF assiprea or otl�er ow+rer or hotder a mat8a6e
Ooes aPG��I own prOpet�y in a(ry alhar � C yq4. what mutdy?
caunry in Ind'are1 n Yes ❑ Na
N wmed Mith sortreorre ather than
�
Yes LJ No
V��M in auastian: AmuaPy AssassaE
a31 PfOpeAy Q MnuallyASSessBd
MoWe Hame (IC 6
__I(wairrantYeaR �
�+e� «� aoveM
Yes ❑ No
Dedufiion aGGroved in Ne amouM d: .
DI'8WC1' 1��.... (�,..pQ„
...
20 _ 20 20 20 _
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SignaturedCOUM'AWita L .•. •.•.•••"•• •.•.• r.daY.Y��
1/ We c�Ay under the penalty of perjury ihal ihe above aM fwega�y .��..��ww� u u�fe�:, � 0� �e� u�e ay�.���..o�a residen� of Indiana aM
ownrs / mn4ad buyer of Ne aforemeniione0 propeAy on date apptiption is filed.
signa2ut¢ (o�mJS hd nM�e) pala (mmM, Eay, yra�
aoio �,�;
F�ason aWiw¢eC
persan (numbrrantlsLaof,tity,ffilo.
142-0.7