HomeMy WebLinkAboutMortgage_Koca""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
, FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R71 / 8-09)
�,.,. Prewibed Gy �ePa�� of Loral GovemmeN Fva�ce �
File Mark
wsrnucnoNS: A�� F�
To be filed in person w by mail with Ne CounlyAuditof or Counry Recorder o/ the county wAere the pmperty is located.
Fifhg Dares: 7J Real Property: Must file durirg the yearlor which tha deducfion is sou�ht � County Auditw
2) Mo6�le / ManWactu2d Homes rrot assessed as Real Properfy Must fi!e dunng Me hveNe (12J morNds �nry Recorder
before March 37 oleach year Ne deduclion is sought. �%C
See reverse side loraddifionel instructbns arM qualifications. ON COUNTY AUDIT
�oontractbuysr-seerestnr�bnson sida)
Ta ' Distri j Key rwmEer I legal desaiptim Rxortl iwmbar Page'um�
�/a-o7-ao/-000. 3Y8-aa8 aoio 359d-
Ass¢sM vapie d mal PW�+b m of Mp�(page / Contraa iMehredness unPaid as of Martgage I Cantraa uWe6tedriess unpaitl as d 4s Me aPW�� the sola
Me�dil.tlmVym Ma�1,WrteMY�� CateoTaDP�n Iega�aeW�bdeawneYl
a,3 g �] .� ❑ Yes ❑ No
It m. what h his I her axaU share ot Ntuest7 1� axned w@h sommna Uhx ihan spause. iMicata with whom
tl'wne m remd ia QAferent than thaf of aOP�� u�difate below. �Is 7th,�e �p,o�pcty m Ouestim: MnuaOy Assessed
� "`°' RoPertY ❑ � � 1.1-
�����a�,�� S 3
AEdress d rtnrtgagee m mnvad se0er (n and sLae4 �Y. sm�e. aM ZfP mde) _. . ..
Drawcr NO..o.Z b.�.P..-....
Name d assignee w alrei owner or halder of martpaga
btlmss W as9grne (munOeraM sbee4 �N: stsfi. ard LP cade) l. � I� d� O. .. ..�� /�.
l.vo-v�-o*.2 r � �°r ...............
� aNppticera��' pmpcty in anY oNer It yes. what oounf/.� Yfiat Taprg .
❑ Yes ❑ No Na
COUNTYAUDROR � �
De0ut6on app�rn'ed'vi Cn amouM of.
20 20 _ 20 _ 20 _ 20 _ 20 _ 20 _
Signatlrte of Camb atlit�r /1 County Date (/mRh, daY. Y�A
✓'7
� /`�
I I We certify u Ne penalry M rjury that the above and (oregoing mfortnation is true and cortect ard that the applinnt is a 2sidefrt ot IrWiana antl
owner I mntract buyer of the afdeme'rtbned property rn date apq'aation is fileG.
K naNre (o N9reme) Date (r�Wh. daY• Yge+)
0
F�ID msident a00�eas5 W app6[ant (wmber antl street �1: ��. � LP mee)
-3 Z � � � l d e s� r�n c��a ,. -� ��-f ��� o
Pason aut)mi'viM sy didy ezeated Pw�er NAUameY a M IC 61.1-12-0.7 Date (m'R+. tlaY. Y��
Add�asa of aWV'ved person (numbe�arM sbae4 �y, sbte. an0 LP mde) _
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