HomeMy WebLinkAboutMortgage_Grimm"'n STATEMENT OF MORTGAGE OR CONTRACT ItJDEBTEDN SS Coun Tovmship Year
_ : FOR DEDUCTION FROM ASSESSED VALUATION" �' "'
:• Sta[e Form 437091R11 / 6-09)
S;,,, � Presai0ed �y OeparlmeM af Lnml Gavemment Finance 0 C T 3 0 2012
File Mark
INSTRUCTIONS: C . �. N�-�
To be filed in person or 6y mail wdh the CowtyAudiror or County Recorder of Me county where the�pmpev is located. F� �� �:
Filirg Dates: 7) Real Pmperty: Must file dunrig the year /or which the deductlon is�sotgh[„�� ��,T� o, i��r,�R � County Auditor
2J Mo6ile / Manufactured Homes not assessed as Real Plnperty��Must file�dunng the twefoe (12) months
betore Mardr 31 of each year Ne deduction is sought ❑ County Recorder
See reverse side lor adtlitional instrucGOns and qualifications.
M 7t(ownerormnlraGby'?r-�eereshiUiort revers�side)
Ec% .
tWmbef / legal deSaiPtirn
-o -3aa-�►.S� -
Mortgage / Contract inde6tedn¢s unpaid a of Mortgage /
Merch 1. turtent ye&r tlatB of app
If (ume m mmN is QAferent than ihat of aDW��4 QWbicate Eebw
w� o,
seuu
W9--
d se0er (numbe` and street
.r or halder of morigage
AdCress of assi9nee (numbera� stree4 ciry. siate, enE ZIP cade)
Dces appli�nl ovm praperty in any oNer If yes, what count�?
county m IrW'aria? ❑ Y25 ❑ No
DeducCOn appraved "c� tlre amoun
20 20
SigraMe of CounNAUEitor
2q
Recoid numbel
unpxid as o( Is Ihe Hppliranl Ne sole
legal or equitade Ow(M!1
❑ Yes ❑ No
Is tt�e property in Question: MnueOy Pssessetl
❑ ae� �aenr O rw,!mMw�a
_ _- aaa
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What Tavn ,7 \ � • � � �� j _ �
C�l `� �� 5��
I J
20 I 20
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20
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1 I We certify under Ne penaliy oi perjury Mat the above aM foregoing mformation is W e and correc[ arM tha[ ihe applirant is a resideni of Irdiana arW
owner / contracl huyer of the afaementioned property on date apPliption is filed.
�nayuejpwnrYs hd nam� n Dale (rbntA. daY• Yme�
FiID
M
of authw'¢ed person (numberarM sbeet �+ry. sfate, aM LP code)
Date (monN, day, yea�
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