HomeMy WebLinkAboutMortgage_Cook�
STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
♦ State Fortn 43I09 (R5/4-03) '
�«
� PrescriDed 6y Department of Lecal Govemment Finar�ce
To 6eRfi ed�'n�person or 6y mail wiih the County Auditor o( the county where the propeRy is located. �� Fi a
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be eflecti�� � 2�005 �
2) Mobile Homes assessed under IC 6-1.1-7: Behveen January 15 and March 2 0l the year fhe ct n �s o be eNective.
See reverse side for additional instn�cfions and qual�cations.
a�onsoq�ysrseqae' _^ _ /„��„ �ry��-�
�" V I J%� C%�% \ � U_�1�
Key number / legal description Record number
o� � 6�3-D0��� `'
/ age number ��
Asse sed value of real property as of MoAgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
Mar t, current year March 1, cury`nl yearQ Q� owneR ❑ Yes ❑ No
\V U ,
If no, what is his / her exact share of interest? If owned wilh someone other lhan spouse, indicate with whom.
If name on record is different than that of applicant,
01 mortgagee or contrad seiler � `
-C�. , _.
s the property in queslion:
❑ Real Properly ❑ Mobile Home pC 61.1-�
Address of mortgagee or cont�aIX seller (number and stre'' -"• °'°��-�ip __"
��--��a�� �6�-
Name of assignee or other owner or holder of mortgage �a
�^�� � �-o d�
Address of assignee (numberand st�eet, city, state, ZIP ,.�+
. `� ��-� ,�'c y
Does applicant own property in any other If yes, what counry? What i axn�y ,,,�,,._,. this dedudion been requested on
county in Indiana? I property for wrrent year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in fhe amount of:
zo �� zo �$_ zo 0 9 2o zo
� 0 ip
Signature County Auditor
zo
Date
zo
We certify under lhe penalty of perjury that the above and foregoing information is lrue and corred and that lhe applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
full
lf3 S.
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person