HomeMy WebLinkAboutMortgage_Champion� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
�FOR DEDUCTION FROM ASSESSED VALUATION Coun ___ Township; —� Year
State Fortn 43709 (R5 / 4-03) � ��1 �� � ��� � %
PrescA�ed by Department ol Loral Govemment Finance 1� 2� � l��
�M. JUL � � �uu'
INSTRUCTIONS: File Ma�
To be filed in person or by mail with the County Auditor of the county where the property is located. � ��/}, �
Filing Dates: 1) Real P�operty: During the 12 months before May 11 of tbe year the deduction is to be affective��il ,`�'
2J Mo6ile Homes assessed under IC 6-1J-7: Between January 15 and March 2 o)the�year.'tbe deducfiori is lo be eBective.
See reverse side for additional ins[iuctions and qualifications.
Applicant (ownerorcontracf buyer- see ie6trictions on reverse side) � •
� ��
Taxing Distrid Key number / legal description Record number
�� D y -/ � � 7
Page number
�� — — Q�
Assessed value of real properfy as of MoAgage ! ConlraG indebtedness unpaid as of Is the applicant th�e� le legal or equitable
March 1, current year March 1, current year owne(? []'i'es ❑ No
Ii no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than lhat of applicant, indicate befow: Is the operty in question:
eal Property ❑ Mobile Home pC 61.1-�
��ne of mortgagee or wntract seller c,/�
ll LjJ , �l — �(D(�O
Address of mortgagee or contrad seller (number and 5t2et, city;sfate, ZIP �
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Name of assignee or other owner or holder of mortgage _ O./_/� /�
/! (7
7"
Address of assignee (numberand street, city, state, ZIP code) Dra���eC `� �
Does applicanl own property in any other If yes, what county? -��\Q• •••""' � een requested on
county in Indiana? Card �af?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 f) � 20 �� 20 �� 20 � 20 20 20
P
Signature County Auditor Date
� We certify under the penalty of perjury that the above and foregoing information is irue and correct and that the applicants was / were
esideni of Indiana and owner of the aforementioned property on March 1, 20
Signatur wners (ull n� Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
II reside t address oj,applipnt � Address of authorized person
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