Mortgage_McPeekry� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
_ • FOR DEDUCTION FROM ASSESSEQ VALUATION
� State Fortn d3709 (R11 / 6-09)
�' I P25C�ibed by DeD��M of Local GoverMleM Fi(13nce► � m e P ��
File Mark
wsrRUCnoNS: e �' I\
To 6e filed in person w by mail with the CowtyAUditw or County Recorder of the county where the property is located.
FrTirg Dates: 1) Real Property: M�st file durirg the year for which the deduclion is sought.
2) Mo6i7e / Manulactured Homes lrot assessed as Real Property: Must fife dunng Ne twelve (f 2) monfhs
6e(o�e Maroh 31 of each year the deduclion is sought.
See reverse side for additional inshuctions arM qualifirations. i
M�wrer�orcontra�]puyer-se�ere5ricbonsonre side)�_ _„
propCM1y d5 ot
no. what Is his l her e�f1 share af in[erest?
�SL—L �i - W /��3/ 5 -O�CJ U aemNni
age / Contract iMehteEness unpaid as of MMgage i wntract indebte0nes5 unpaid as
i 1_arts�nt year l date ot appGcation
If rwne m remrd "a Sfrerent ttan that ot a0p6cant, uWifate bebw:
cfty, staM, aM LP code)
or mher owner w hdder ot rtprtgage
Mdress of assignce (number aM sheet ciry. sfate, aM Z/P code)
Oces appli�nt own praperry in any oNer I If yes.
counry m Indena? �.. �..
20
approve0 m ihe amount oE
�
If owmed vriN mmeone oNer ihan spouse, iMirate wifh whom
Counry Aud'rtor
Page numbrl
r epuitade wrt�eh
❑ Yes ❑ No
��� m ���
.� �32,c�3.�
COUNTYAUU � U� / y � f G'
�' �T';1
�/� v�
20_ � 20
�
I I We certify uMer Ne penalty of perjury Mat the above and foregoing infortnalio
owner I tontracl buyer of Ihe afo2mentbned property on date application is filed
state,
Person auNOraed Gy duly exewted Power o(Attvney or �y
person (numberarM sDee4 ciN, slate. an0 LP mde)
�i3--
-� �;2
iJ
+�Y
� No
aaM
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