HomeMy WebLinkAboutMortgage_Clark (2)"'34 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Tovmship vea
_,�_,. + FOR DEDUCTION FROM ASSESSED VALUATION
• Slate Fortn 43709 (R71 / 609)
�' „r � p�¢sm'bed M ceG�eN of Lowl GovemmeM Finarua!
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INSTRUCTIONS: �
To be filed in erson or b maR with the Coun Auditor or Coun Recorder o/ the coun where the ro F� �� ���
P Y �Y N N P PQrtY ��t�.
Fd"ux� Dates: 1) Real P`operty: Must file during the year /or which the deduction is wught. ,In V 1�'Z County Aud'rtnr
2) Mo6de /Manufactured Homes rrot assessed as Real Property Must Ae dunng the twelve (12) mont�tl
6efore March 37 of each year Me deduclion is soight. Counry Recorder
See reverse side !or addtional instrucGwu and qualificatbns. C'�'
Appfxant (owrierw contdU b re' m re " e) �
COUN7Y AUDITOR
Taan9 �istria l(ACmqnber (,Lgal desaiPbA^ � _ _ '" RecorE �r Pa�elY:�i�i.
)Uf / �
�3I �5 �115 i iRf 2XdGi SiNIB OI I(11CIPSi/
m remd Is SRfuent Nan ihat ot app6cani, 6Mkate 6ehw.
1 es of Mongage / ConVac3 hWe6tedness unGaid as of LS Ihe ePP�ni Ne sde
tlate of app�6on � w equitable v�meYl
❑ Yes ❑ No
It awned vri� sommne oiFwl Man spoise, IM'�afe WN MRiom
!s tne v�v�v in quesrian: annuaM nssessed .
❑ Real P(oPeAY Q MmUaIly0.55e55ed
n.eeoe r� nc �-�.i-,
rlameafmorteasea«cw,rdasener � � ) �{ , `
i
t..
Aedress ot mort9a9ee a contrarl seDer (numher ard stree; cifY, s�te, aM LP coda)
Name of azsi9nea or Uher owner or haldu of mx�age
AEC+ess ot atv9�ee inumber arM sheet dh. sta:e, and LP oodel_ ...
Does epplimnt own Pm7enY in any oNer �� �{y /( rn�� �r
munry m Indmra? ❑ Yes � ' • n, ` " � '
� {� IJ,/G �-
DeEuction ePPmved'c� Me amwnt a` I� r ��%' � .
_�
requnsted m pmpGty
❑ Yes ❑
20_ 20_ 0_ 20_ 20_
Sqrmwre or co�nry nuaitcr cou�y oata (monm. ear. yea�
I I We certity under Ne penalry ot perjury that the above and foregoing infortnation is we and cortec[ and that the applicant is a resident of IrM'�ana aM
owqe'(contrad buyer of the aforementioned property on date appfication is filed.
Slare re! e/s fWl rmme) / n A . Date (month. daY. Nea�
PGSwi�duNortred Dy Outy executed Poxer of Attamey ar 6y IC
Pdamss of auihor¢ed 7e�^ (numberana sbee4 �%Y. stat& e
te (monrh. daY• Y��
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