HomeMy WebLinkAboutMortgage_Lamey (14)^'�o STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
• FOR DEDUCTION FROM ASSESSED VALUATION
' Sfate Fwm 43709 (R71 / 6-09)
•j' - e Presvibed by DePartrtient of Lixal Government Fnar�ce
�u.
INSTRUCT70NS:
To be filed in person a 6y maii with the CourtryAuditor orCounry Rewrtler of the cuunry where fhe property is bcated.
Fii'mg Dates: 1) Real Pmperty: Must fite durirg the year /or which the deduciion is sough[.
2J Mo6Be / Manufactured Homes rrot assessed as Real Property: Must file dunng the M1velve (72) months
6efae March 31 of each year the deduclion is sought. -
See reverse side /or add'rtionaf instmcGOns and qual'dications.
I Aoofiwnt (owtElor conhaC 6wu- see resMC�ns an re sidel
��������
ur�en[ year
ofinterest?
on
Name ot moMgagee a contraG seller
Address o1 rtwrtga9ee a conbac[ sell
Name of assignee w other ovmer or Y
3-o5=,�ao-
gage/Contractindehtednes
i� 1, artent yeer
aM sfree4 �}: s+ate, end LP codej
>f assgnee (nurnOr! antl stree4 �: sfate, and LP code)
litant own property in any oNer If yes, wIv
IrW"ana? ❑ Yes
❑ No
���m�:
zo_
Signad�re W CambP�W�icor
I/ We certity uMer the F
1 as of Mwt
date
rc �ea �m :
r�'- � /�
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�.q ►� � �/ , �a t-I-
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FW re4tlent address of appfrcant (number aritl s0ee4 pN, state,
t�9�1 S �ao �, Na����.d �;, S�ti
Pe�son aW�¢ed Cy dWy exm'sd Power of Attm�ey w by IC E
Pdtlr�ss of auNOraed person (number arM sbeet cBy, sbt¢, an
°'o�UN COUN7Y
`�op�/� ,� �
Yes LI No
Is the property in auestion: MnueM Assessed
�Real Property ❑ Mnually Assessed
Na dedudion Deen 29u�teE m propeily
urrerrt Y�n r-i .. r-�
_ 2� _
M. daY, Yea�
a resident of Indiana and
Date (rtw�th. daY• Ye�I
ia-3►-�ola
�
Data (mon�h. daY•Y��