HomeMy WebLinkAboutMortgage_Milheiser'°n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun a nshi Y r
__ ; FOR DEDUCTION FROM ASSESSED VALUATION
• .� � State Fortn d3709 (Rit / 6-09)
�' �«. � P2saihed M DeCa�rq of Lod Gwemment Rriance
�VSTRUCTIONS: w�m.fu
io 6e filed in person w 6y mail with the CountyAUdifor or Counry Recorder o/ the counry where the property is located. F C: �� �
Filing Dates: 7) Real Proparty: Must file dunlg the year for which fhe deduclion is sougM. � Coun u
2� Mobde /Manufactured Homes no� assessed as Real Property Must file dunng the lwelve (72) months I�1 2� n�p1'f OR
befo2 March 37 0! each year Me deduction is sought. Bg(�N C�1Sti+ryYRerr� der
See reverse side !or additional instructions and qualifications.
'� MP�nt (ownar w contrarl6uyer - see resMUiqnsPCi (iverse sitle)
Asessed vdue dmal p(apeny as o!
Mai[�h 1. arren� year
mretoftl
Name of
Key rw t�ber I Iegal desrnpnon `�
�-C� - II
MoRgage / Contraa iMehtetlness unpaid as of Mortgage
Martl� 1, artent yeer tlate af ao
Mr e� share of interesi?
bebW.
Addre55 W mortgageelor contrap SpAer (number and s0ae1, ciry, sfate, arN ZIP code)
l
Name of assynee or ofher owner w hdder of rtnrt�age
stree4
DoeS appliWnl oun properry in any olher If yes.
Cqlfl2y I(1 �11�0fid� r,-!�
❑ Yes LZTno
If wmed vnN snmeone
�L
Recdd num0er Page number
D�� `
unpaiC as of Is il�e a00���1 Ne u
sVO�se.
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property in puestion: Mnually hssesud
al Property ❑ Mnualy Asspssed
Modle Fiane (IC 61.7
Has ih¢ tletlurfion been re/�9uesteC m P�nY
FOlWlRIILYPan 117f1 1'l
COUNTYAUDROR
Deduction apprweC in 1tre amount af:
20 20 2q 20 20 20 20
Signature W CamryAWitw Counry Date (month. daY.Y��I
I/ We certify uMe� the penalry of perjury that the a6ove and toregoing in(ortnalion is We and cortecl and Nat Ihe applinnt is a resident of IrWiana arM
owner ! contrad buyer of the aforeme�ed property on date application is filed.
' naNre (awnerY hArume) . Date (nmfA. day, Yeah
' ..n..�, o. � m ��
F tl resident a0dress of appGwnt (numDer and streef, dry. state, aM ZIP cotle)
9 � � � a�-�-
Person autM'rzed Gy dWy ecutetl Power of Attamey rn Oy IG 61.1-12-0.7 Date (rtronN, daY. Y3a�
Address of auNatred person (numDer a� stree4 �y. sfale. antl LP cotle)