HomeMy WebLinkAboutMortgage_Gomez�� STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
G FOR DEDUCTION FROM ASSESSED VALUATION Coun w Year
: ! Sute Fwm a3709 (RS / a-03)
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PrescriDetl by Department ol Local Gtivemmen� Finance
\ iNSrRUCrioNS: APR 2 9 200�
File Mark
To be filed in person or by mail with the County Auditor of the county where the property is located. �
Filing Dates: 1) Real Property: Dunng the 12 months before May 71 of the year the deduction is to be e�
2) Mo6ile Homes assessed under IC 6•7.1•7: Between January 15 and MarcA 2 o/!he e i�o i�{��t effective.
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See reverse side for additional instructions and qualifications.
Applicant (own O contract buy � isee resMctions on rever ide) C�o nt � Z
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Taxing Distrid Key number legal description Record number �� /
�j'✓��i� ( 1'1 i, u� �(p � O�d 3—�U Page number ��/
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Assessed value of real property as of Mortgage / ContreG ind btedness unpaid as of Is the applicant the sole legal or
March t, wrrent year March 1, wrrent year ��Q � � Q owneR ❑ Yes ❑ No
no, what is his / her exact share of interest?
If name on record is different lhan that of appticant, indicale below:
ti�
ame of mortgagee or contraG seller
'�" Y�"��
Address of mortgagee or wntraci seller (number and st et cily, state, ZIP
of assignee or
Address
owner or holder of mortgage
(numberand st2et, city, state, ZIP
Does applicant own property in any other If yes, what county?
county in Indiana?
Deduction approved in the amount of:
20
Signature
with someone other ihan spouse, indicate with whom.
What Ta
COUNTY AUDITOR
20 0/n 20 �� 20 g�
J � /
County Auditor
s the property in questian:
❑ Real Property ❑ Mobile Home
��iyu-�� 1� -��'�'03
�.ti,�-w- kJIG
O�OU/ � ,3 7 S�l
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20� 20_
Q
Date
T�]
6-1.1-�
ted on
s ❑ No
' We certify under the penalty of perjury that the above and foregoing in(ormation is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
3ignaturg (owners full name
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Full re 'd�nt addre of applicant
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Person authorized by duly executed Power of Attorney
or by IC 6-7.1-12-.07
Address ofauthorized person