HomeMy WebLinkAboutMortgage_Larson�
STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�• ! SUte Farm 43709 (RS / 4-03)
\ N rn
v. PrescnDed by Depertment of Lofal Govemment Finance 1�� �� # �,j �
S �7 �1
g
�+ �i�.:�-
�TRUCTIONS: �C Ca�` 9 ?p03
� 6e filed in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: i) Rea/ Property: Dunng the 12 months before May 11 0/ the year the deduction is to 6e effective. � " ���
2) Mobile Homes assessed under fC 6-1.1-7: Between January 15 and March 2 0l tAe year fhe deducfion is to be �e6ective.1
,.._1 ,�.��....-.,; p
See 2verse side for additional instructions and qualifications. ��!'� �.:;��•,+�� �
_ ! �„BSCi4 C�'=�
D� a -ooa ys- �J
Assessed vafue of real property as of
March 1, current year
no, what is his / her exact share of interest?
side)
Key number / legal description
���
number
�a _ y�a�3
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, currenl year owner? ❑ Yes ❑ No
i a.a s�od
If owned with someone other than spouse, indicate with hom.
�G -/a -or-/�� �oo. ��-��
name on record is different than that of applicant,
of mortgagee or contract seller
of mortgagee or wntrect seller (number and street, city, state, ZIP
of assignee or other owner or holder of mortgage
of assignee (number and street, ciry, state, ZIP code)
Does applicant own property in any
countv in Indiana?
Deduction approved i t e amount of:
� I �
20 20
PTR4'ioA
Signature
' If yes, what county?
� `�. 5 c��
20 fL� 20 _C
�
Counry Audiror
What Ta.
AUDITOR
20
s the property in question:
❑ Real Property ❑ Mobile Home QC E1.
Drawer NO Q �-.. �4!��..
/
Card NO . ..................... 9uested on
� Yes❑ No
�
�
�
I/ We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that lhe applicants was ! were
a resid ndiana enil�owner of the aforementioned property on March 1, 20
/ /J�I resident address of
Person authorized by duly executed Power of Ariomey
or by IC 6-1.1-12-.07
R R-1 Qe x� 3,r IAddress of authorized person