HomeMy WebLinkAboutMortgage_Blacklockj�� � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
's'�; FOR DEDUCTION FROM ASSESSED VALUATION ' u t 7 hi Year
�! • State Fwm 43709 (R6 / 5-061 �
�� Presaibed by Department of Local Gwemmen� Finance �OOQ
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INSTRUCTIONS: �-yy� �f
To be filed in person or by mail wfth fhe County Auditor of the county where the propeRy is located. �� ��
Filing Dates: 1) Real Property: Dunng the 12 months befoie ,lune 17 0/ the year the deduc6on is to be �BBCJ�. COUNTY AUDITOA
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of fhe year [he deducUon is to be e/fective.
See reverse side for additional instiuctions and qual�cations.
�cing Dislrid �
��
Assessed value of real property as of
March 1, curcent year
I( no, whal is his / her exad share of
If name on
of mortgagee or
Address of mortgagee or
resMctlons on revqse side)
Key number / Iegai description Record number
�L-�.�-��-.od-ao�. aooB
/� ( —� � Page number �6�
MoAgage / Contrad indebtedness unpaid as ot Is the applicant the sole legal or equitabie
March 1, current year ownef? ❑ Yes ❑ No
� � � � `�'
If owned with someone other than spouse, indicate wilh whom.
ihan that of applicant, indicate below:
(number and stieet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
of assignee
s[ate, ZIP code)
Does applicant own property in any other I If yes, what county?
counry in Indiana?
Deduction approved in the amounf of:
20 � I zQ p c
� 'i
Signature
❑ Real Property ❑ Mobile Hmie (IC 61.1-
Dra���er NO.��a..�. .
.. � . _
Ta Cal"d �'�.
COUNTY AUDITOR
20 i � 20
��
_ County Auditor
�
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.��3'Q� .....
20
Date
20
�sted on
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ceAify under lhe penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
leni of Indiana and owner of the aforementioned property on March 1, 20
�sidenf address of applicanl
D� �• ��uM (,�+> �Yd-►1Li5�� �li
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized