HomeMy WebLinkAboutMortgage_Seifers""� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship Year
_ , FOR DEDUCTION FROM ASSESSED VALUATION
Stata fmn d3709 (R71 / 609)
�' Prewibed Ey Departmerd of Loml GovemmerR Flrerr<
File Mark
INSTRUCTIONS: '''���jj{'''���
To be filed in person w by mail with the CountyAudilw o� Counry Remrtler o/ the counry where the properry is locat�d..l F med :
Filing Dates: 1) Real Property: Musf file dunrg fhe year fir which Ne deduction is sought. u di
2) Mo6de /Manu/actured Homes not assessed as Real Property: Must file durirrg the tweHe (12J mo �
before March 37 o/each year the deduction is sought. ❑ �^�Y R��
See reverse side for addiliona/ instrucG'uns and qualifications.
Appfxant (owner orm�tr�t�Ayer- sea SesLirdurss verse ffie). �.l i .� � . �_ �
Atsased vdue m real pioperty as
A1a'N 1. a�reM ym
11 M. Whdl 6 hl5 i 112I 8lf2Cf Sh2fB 0/ Y1tElP5t?
�.� v �, — C:fJof •/ J i
ge / Contraa indnbtetlr�s unpaid as N
1. wrtent year
If OWIICE
tl name m tcmd is 6Ruent than thal of aPP���. mO'vzte Debw:
��«m,uaa
r�lan,e or asvgnee or «ne. awnu «nomer ot mo,cgaye
AOOress of assignee (numbei ard svee; ray, state, and LP wCa)
Dces a�nt ovm proprlry in eny ahef I If yes. what munty? I What Ta�drg D'¢tr'ri?
mumy in Ind'ar�a?
❑ Yes ❑ No
numE�
trWe6tedriess unpak as of
Yes L� No
�-
6 the 7�PenY in GuesOOn: MnueM AssesuE
� Real Pfope.rt' Y ❑ ��Y �
a+o� r�,� nc s
Nis tledu�lion Eeen fequested m popaty
unmt yealt � _ _ �
COUNTYAUDROR
Detlucoon apprwetl in ihe amount of
20 20 _ 20 _ 20 _ 20 20 _ 20
Sig�unne W Co�mry Audiwr Counry Date (rt�onth, daY. Yee/l
I/ We certify under the penalry ot perjury that the above and foregoing intortnaUon is true and cortect arW that the applicant is a resident of IrWiana arM
owner I mntrad buyer of Ne aforemeirtioned property on date applicatlon is filed.
h hID � Date (nnntli. daY. Ya�)
FW 'dent addrea of appGdnl (numEer and streaf, tiry, state, arM LP mde)
9!6 iU. Esf S�-. ;�ce�v�+ T� 76 O
auNOmetl E1' dWy exeaced Power o( y w by IC G7.1-1 -0.7 Date (mmfh. deY• Y��
AdtlresS of aW�or'vEd person (number arnd sLee; dry, sfate, anC ZIP mde) .
� _ ��