HomeMy WebLinkAboutMortgage_Riley (3)"' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun 7 sh r
ir^
� FOR DEDUCTION FROM ASSESSED VALUATION
� Sta[e Fortn 0.1709 (R71 / 6O9)
S uu � Presmbed E1' DeP��erd ai Lxal GwemmeN Fnance
iNSrnucnoNS:
To be fiied in erson or b mad wrth !he Coun Auditor or Coun Recader o/ the coun where the F �� �'�
v r N b N a+oaenr � rxated.
Fi!'mg Dates: 7) Real Pmperly: Must file during the year for which tha deducUon is saught. uditnr
2) Mo6de / Manufaclumd Hwnes not assessed as Real Property: Must file dunng the hvelve (72) montq§� gg N�� ��� �R
6efoie March 31 of each year Me deduclion is sought.
See reverse side /or adtlitional instrucfions and qualifications.
APP�� (mme�or,cpNrdC bnY�' see m9nUims m reverse vQa) \ -^
Y ) .1L1 \
w�ee,.�� mre� �«r, as w
MaN� 1. aarent 1Rar
N�
If ro. whai Is his / her e� share of
name an
- �''�-1�6-.�01-�L�O,
MortGage / Contract intle6teEness unpaid as of
Marr}i 1 airtent yrsr
�a� �..�(ti�_ �ri
mortgagee w mntrsct seller �
ir3�k oF��:�
ot rtnrt�agee or cantract uUer.(nwribar and svee; rdY. sb�, ar.' ��a wde)
/' '
aszgnee w othrl avmrs w hdder o1 mortgage
Add�ess ot aiti9�� (rwmDer aM sbeet �
��
Dces epplinnt avn DADQnY �^ any olher
munry In InCiaria? ❑ Y�
DeducUOn app�wed in Cm amwnt oF.
20 _
SgreMe N Co�mb A�Mitcr
AM
Remrd num0er Page numbef
�� ��
unpaid az of is Ne appfront Ne sole
legal w iraWe amert
�Yes n No
H ovmeE wiM sameone ath� ihan spouse, iMkare wtth wlwm
h property in 9uesUOn: Mnually Assessed
�ea� a'oaeNV ❑ a,nnua�ywssessea
nbea� r�e nc ��.
'slate.arMLPcade) Dl•a�ti'e1.(`r (� '
Ify�..�n,al� `0... .a L!�--]..
No Cal'CI 1�'O. . ...� I I�
COUn.. . ,
20 _ � 20 � 20 _
County
20 _
een requgted m
❑ Yes
20 _ � 20
Date (month. daY.
I I We certify under the penalty of perjury that Ne above arW foregoing intortnation is true and wrrect and that the applicant is a resident of Indiana and
owner % mntracl buyer of the aforementioned �roperty on date appfication is filed.
�ranue (qwnals fiAremey •� .. /1 A Date (mw++A. daY. Y��
a t(numbef arM sDeet, dfy; sfate, entl LP ootle)
� o�K �� �io-k\�..,� �; �.,
autha'aed person (number antl sbeef, cdy, sbfe, aM LP wde)
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