HomeMy WebLinkAboutMortgage_Sampson (2)`O�"° STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' ' FOR DEDUCTION FROM ASSESSED VALUATION Cou � -,g.Township Year
�, ��� Slate Form a3709 (R4 / t0.01) k? j�.--j
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� PrexribeO by Depanrtren� ot Local Govemment Finance -�LJ i� i
A U Z003
INSTRUCTIONS: File Mark
To 6e filed in person or by mail with the County Auditor of the county whe2 the property is located. / � /7 /I
Filing Dates: 1) Real Property: During the 12 months be(ore May 11 of the year the deductron is to b e'cfN2. J -t�;-!t-�/'/
2) Mo6ile Homes assessed under IC 6-1.1-7: Belween January 15 and March 31 of the yea�t�e��d�tion'is,to`6eie((ective.
See reverse side Ioradditional instiuctions and quali�cations.
Appiicant r or cont ct buyer - see re cUons on revers ide)
W �- �
Taxing Distrid Key number / al description Record number
Q � � �/� rDO � Page number
C.VJ
Assessed value of rea operty as of Mortgage / Contred ind�le ness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, current year �� (p Q Q owneR ❑ Yes ❑ No
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below: Is lhe property in question:
❑ Real Pmperty ❑ Mobile Home QC 61.1-�
�ame of mortgagee or contrad seller [
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Address of mortgagee or contract seller (number and street, ci , state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and streef, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for current yeaf? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 Q� 20 �� 20 �_ 20 �g_ 20 �_
� 30� � � � P
Signature County Auditor Date
i/ e certify under lhe penalty of perjury thal the above and foregoing infortnation is true and corred and that the applicants was / were
� r sident of Indiana and owner of the aforementioned property on March 1, 20
i ature (owners II name) Person authorized by duly executed Power of Attorney
' or by IC 6-1.1-12-.07
F il resident address o app i Address of authorized person
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