Mortgage_Krug�
^��, STATEMENT OF MORTGAGE OR CON C I �NESS
• FOR DEDUCTION FROM ASSESSED V�UE4�t� ��
r Sfate Farm C3709 (R71 / fa09) o�� � g 10
�' � Presmted M ceG�aN of Locai Govemnrent Frwice
Coun Tovmship Year
4��
File Mark
INSTRUCT70NS: G 7' R
To be fiied in person a by mail wifh the CounlyAWitor or Counry Recorder a/ the counry whefe the �%t�� located. Form med witn:
Filirg Dates: 1) Real Pmperty Must file dunrg the year for which fha dedudion is so I�t�VNZ l � Counry Auditor
2J Mobile / Manufectured Homes rrot assessed as Real Properly ��lunng the hvelve (}2) months
before Maich 31 of each year the deduclion is sought � County Recorder
See reverse side lor additional instructions and qual'dicatbns.
Ap � mieror Cbuyu'see�' m versesede)
T" 'rl Key ruan6er / desoi^ption Remrd num6et Page numbni
//.tOM.Ai.. av0 _1 /_ _ � N - z.0 7 /1/Ll � � � Q��� a. Ca� � �c L� iF �..
on
peaperlyasof
e�ct shara o',
NRerent Ihan fhat ot app6canl, trdicate Debw:
of mortgagee w mntracl seUer
Yr�.
Pdd2ss o} rtiortgagce w WntraG seuer (numDeierN slreeS u�: stale.
Name ot a4i�ee or otlrer ownu or hddu af mortgage
ALdrew of assignee (numbrs and sfrecL �: s(ate. and71P cade)
az
��
as d I Is Me aPPfaanl tlx soie
lapl w equitaNe owneR
n Yes n No
tt awned wi� wmeone ahel tlun spo�sa. 6Micate wBh whom
GertY in qurstion: AnnuaDy hssrssed
ProPeNY ❑NV1UaPjAaessed
MaW1e Fiane !IC 61.
�aPpluant rn�n property in any other I If yes. what munq? I What Tarifg Datrict7 I Has Na dtducUOn been mquested on propeny �
munry in Ind"mra? ❑ Yes ❑ No tor wrtent YraR � Yes ❑ No