HomeMy WebLinkAboutMortgage_Burns�
STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� ! Sfate Fwm d37W (RS I 4-03) �
w.
PrescriDed by Department of Locai Govemment Finance
wsrRUCr�oNS: A P R q�� "�� Z005
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1J Real Property: Dunng the 12 months 6efore May 11 of the year the deduction is to be efl
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year t� ective.
See reverse side for additional instn�ctions and qualifrcations. GIBSONBCO(�l�j �{T ITOR
GI 30
(owner or contract
Taxing Disirict
see restrictions on reverse side)
Assessed value of real property as of
March 1, current year
If no, what is his / her exad share of interesl?
Key number / Iegal description Record number
_ Page number �9 c'
^ l
MoAgage / ContraU indebtedness unpaid as of is the applicant the sole legal or equitable
March 1, current year �QJ �oo,/ owner? �es ❑ No
�
If name on record is differenl lhan that of applicanl, indicate below:
of mortgagee or contrad seller
owned with someone other than spouse, indicate with whom.
of mortgagee or contracl seller (number and street, cify, state, ZIP
Name of assignee or other owner or holder of mortgage
(number and street, city, sfate, ZIP code)
Does applicant own property in any other I If yes, what counry?
county in Indiana?
Deduction approved in lhe amount of:
+�/L/��
couNrr a�
20�� 20��
Q �
County Auditor
iv • ciciv . cicooc -v u r
s the property in question:
�eal Property ❑ Mobile Home QC 61.1-�
�=Y "errO I.. _;Q.��
D ���. S,
Ca�a�� .
20
�
20
Dale
i requested on
? � Yes 0 No
zo
certify under the penalty of perjury that the above and foregoing information is true and correcl and lhat the applicants was / were
lent of Indiana and owner of the aforementioned properiy on March t, 20
(owners full name)
.. t /%
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
it addressbf applicant Address of authorized person
`� � 3 � �.��.vu,ca��r> .�-�f