Mortgage_Williams (3) .-4-1, .T1_;•,,,,, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou Township Year
;�'`'`t FOR DEDUCTION FROM ASSESSED VALUATION � 7 Township r a+
State Form 43709(R13!10.15) �� )tx-17
�-- Prescnbed by Department of Local Government Finance la-019-t(P
INSTRUCTIONS: DEC •d- Mark
'
lirfiled in person or by mail. ' °I'-_.watt
g Dates 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the prope tl t • Co.•• Auditor
located on or before January 5 of the immediately succeeding calendar year. I -lI'+f!N i County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor@
whet the property is boated during the twelve(12)months March 31 of each year Me dedrrctiorr�
See reve side for additional instructions and•ualifrcations.
Appfian or codtaa buyer- terse side) ✓ y
� )buyer Ck ( /QiW Lll/ 01'•L'/3
T g D' rthber! description Record ter a nom r
A value of teal property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contrad indebtedness unpatd6 a Is the applicant Cie sole
assessment date,amen/year assessment date,current year date of applratprL ,-, / / /S OO legal or equitable owner?
•••2 V.;(a° . ❑ Yes ❑ No
If no,what is his I her exact sham of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applant,indicate below. Is property in question:Annually Assessed
Real ❑ Annually Assessed
title Home(IC 6-1. )
Name of mortgagee or con bad seller Qt ��JJ �,�., ^
/( t7 Y7L\ �� �(/
-
Name of assignee or other owner or holder of mortgage
Address of assignee(number...a t city N••e, .nil LP code) `�� / / ' �t / //r ? /7/led
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