HomeMy WebLinkAboutMortgage_Gullickson^�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTE[
__, - FOR DEDUCTION FROM ASSESSED VALUATION
State Po�m 43709 (R71 / 6-09)
4' ,.r f PresaiCetl by DePaRment o( loral Governmenl Finance
WSTRUCTIONS:
k 6e filed in person or by mad with fhe CountyAUditor or Counry RecoNer o/ the counry where
F7ng Dates: 1) Real Pmperty Musf file dunng the year (or which fhe tleduction is so�ght.
2) Mo6�7e / Manufadured Hanes rrot assessed as Real P`operty. Must file during
6etore March 31 of each year the deduclion is swght.
See reverse side for additional instructions and qual�licafions.
AooGrant(oMn(rorcontrartbuvet-see�estricbmsmre� sidel__ . .
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If rart�e
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Coun Tovmship Year
File Mark
the ��� � �
the� �unry Auditor
y � ❑ County Recorder
�p 2 6 20
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Key I legal drsoiption CO NR�la ��l�,�R Page nu
-f�31-400-��o��h4- �
9 e/ ConVa�x inde6tedness unpaid as d Mwtgage I Con udebtedness impaiE a d Is Ne app8cant ihe sde
M�art�ha8 wrtent Eate o( app6mtm kgal or equilaCle ownM
SO O ❑ Yes ❑ No
telest? If avmed wiM someone dher than spouse. indimte with whom
W aDP��• uM'uate bebvr. is C�e W�PeRY in puestion: Mrnia�y Pssesud
❑ Real Property Q MnuallyAssessed
Name M mwt�a9ee « mntrar2 seAer ��
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Address W rtnrtgagee or contrad se0er (numb� and sveel, ray, sbte, aM ZIP code)
Name of "`"�nee or oMer owner or hdAer of mor�gage
Dces applimnt oan praperty in any i
munry in IrW'ana?
❑ Yes
m'
�vhal
for
m ptapnlly
COUNTYAUDROR
DetlucCOn appmved in ihe amount oE
20 20 _ 2q _ 20 _ 20 _ 2q _ 20 _
SigfaWrc of Cour:bAuditor Counry Datc (monlh. daY• 7'�a�
I/ We certify under ihe penalry of perjury that the above anE foregoing intortnaGOn is We and correct arW that the applipnt is a resident of IrMiana arM
owner / contract buyer of the aforemerrtioned property on date applicatlon is filed.
� Si naWre Ys full iume) Date (monfi, day, ysa�
� F �O o ppGcanl(nu rarMSfreet ��Y,�. Pootle) ^, 1,�
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P�.,w� autho(rzed by tluty esecutetl Power o(AVnney w by IC 61.1-12 o�e ��r�o.,m, day, yea.�
Pddress of authoraed person (number arM sUCet, dty, sfate, antl ZIP aode) _
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