HomeMy WebLinkAboutMortgage_Van Antwerp^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun'
: � FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R11 / 6�05)
� PmsvibeE by OeparimeN of LorW GwemmeM Fuance
� INSTRUCT70NS:
To be filed in person w by mail witA the CountyAuditor or Counry Recorder o( the counry wheia the property is located.
Filirg Dates: 1 J Real Pmperty: Must file dunng Ne year for which the deductlon is sought.
2) Mo6ile / Manu/actured Homes rrot assessed as Real Pruperty: Must file dunng the fwelve (12J months
before March 31 of each year the deducfion is sought.
See 2verse side tor addifional instruclions and quelifications.
AppGCanf(ownarolwnt2C r-seemsflich'msMw mverseside) /f
/� .. � � 1 Y/�. �—Y � I/1 . w / 11 ��i •� n A
�I (\— 9 C�
s�i::n�
If no. what Is his / her exact share of intemst?
If riartie an �ecad is dfluen� Nan Nat of appOCaN, u�tlicate bebw:
'D
RecorA
Is Ne aPPfaart �
legal or equitad
❑ Yes
Is tl�e OroPeM in questim: MnuaOYASSessed
❑ Real ProPeKY ❑ �!!�1! �
Name of mortgagee ar mntract se4er ��
Pddrea of nnrD3agrx w mntraG sWer (num6er aM sheeL �Y. sbfi. aM LP code)
Name Of assignee w other ovmer or holder of mort9age �
Address of assi9nee (number aM sbee4 �Y, sfale, aM Z/P code)
Does eppliCant wm property in any oNer It yes (' —"—'^K 0e0ufYion
counry in IMiana? ❑ Ye5 ❑ r,o ��/ A�1 A N T(J E-IP � G�(f�/�j �1 yeaR
Da7uc�on aGM� u� ttre anwunt of. /� ��/`�' �
20 _ � 20 � 20 _
No
m p�operty
❑ No
20 � 20
SigreWre W CounryAWitor Date (monN. day, ysa�
� �...�
I I We certify under the penalry W perjury that the above and foregoing infortnaUon is We and mrtec[ and ihat the applirant is a resident ot IrWiana aM
owycf I contract 6uyer of the aforementioned property on date applicatlon is filed.
Persort auNO�aed Oy dWy executetl Power of Attmiey or by IC 67.1-12-0.7 I Date (monN, day,
Pddress of aWia'vetl person (numDer ami sbeet, dry, uafe, and LP code) .