HomeMy WebLinkAboutMortgage_Wagner (3)""* STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7ownship Year
__, + FOR DEDUCTION FROM ASSESSED VALUATION
� S�te Fwm d3709 (R71 / 6�05)
�' � Presaibed 6y DepartmeM of Loml Cmvemrtrerit Frunce
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wsrRUCnoNS: Fqm�m
To be lled in person w by mail wiN the CountyAUditor or Counry Remrder o/ Ne counry where the property is IocatedN � V (� i7
Fi7ing Dates: 1) Real Property: Must file dunrn� the year (w which Ihe deducfion is soughf. Cqunty AuditOr
2) Mo6ife /Manuladured Homes not assessed as Real Properry: Mus! file dunng the fwelve (72) months
6efore March 31 oJeach year the deduction is sought. `-7�� � ounry Recorder
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See reverse side !or addi(ional instnicfions and qualihcations.
Taring bistr'vi Key rw ber I
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As�zC vaLe of mal qoperty as o� M
Mamh 1. anart ym M
It ro. what is his 1 nn exaG share or interest?
I( name m remid a diRerent than Nat of appOpnt, u
Name of rtiortaaaee or mnVaa seller
�3-�.03�` '
Convatiirdehtednessunpaidasof Mortgage/COnract'vWebteEness
rtp�yt year ` date of appGmtion
ot m«rqaqee or oono-aa seoer (wmeer erd sveec dlr. srare.
Name o1 assignee w otlw owner or hdtler W nmgage
AECmss of av9gnce (number aM snee4 my. s+a+e.
Does appiicant oxn property
mumymindia�a? r
approved in ihe amount of.
20 _ � 20 _ � 20
snmeone aher ihan spouse, iMicate with whom
rita6le wrtie�
Yes ❑ No
Is Ihe pmperty in pues�on: MnuaDy Assrssed
❑ Real Properry � ArmuallyA�sessed
Mobile Fiane fIC 61.
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Sigranne N Camb nueimr
I/ We certHy uMer the penalry of perjury that the above aM for.
owner! contrad 6uyer af the afrnementloned pmperry on date e,.....----.. .- •••-�-
Wre o� ersfiAlrertre)
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Fuil ident aEdress of appfirant (num0er entl sLeet, rily, sfat an ZIP e)
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n auttq(aed Ey dury esecuted Power of Attorney or by IC 61.1-12-0]
Pddress ot authar¢ed person (num0er arM sbee; tify, state, anE LP code)
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Date (�. daY. Y��
tlay, yea�
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