HomeMy WebLinkAboutMortgage_HiattSTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun
_ • FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R71 / 6-09)
�' � PresoiEeE by Departme�ri of lo�i Gwemment Firwice
�«.
INSTRUCTIONS: � �
To 6e lled in person w by mail wiN the CounryAuditor or Counry Recorde� o/ Ne counry where the pmperty is ted.
Filirg Dafes: 7) Real PropeRy: Must file Gurim,7 the year (or which the deducfion is sought.
2) Mobde / Manufadumd Homes not assesced as Real Property: Must file during Me tweNe (72) monMs
befae March 37 o/eacA year the deduction is swght. ��
See reverse siCe for additional instructions and qualifications.
IADO�cant( mnvartbt7e�-tea D+reverseside) � 1 • . � —7
�� .�-a�-�oo-
poperty az ol ge/ Contraa irde6tetlne
1. airtent Yrar
it iro. what Is his / her eraU shara ot int�est7
ro
tl name m femrtl is Q(Rermt fhan Nat W a7P��C uiGin� helmr.
Name of mxtgagee ar mntrati u9er
Addrest of mortga9� or mntraG uAU (nu
Name ot assignee or oNer owner ar holder-
Atltlress of assignee (numberaiW sbee4 m
Dces eppliiam own proprnj in any oMM
couMy in Irdiana? �
❑ Yes
or�uction aca�� in are amount
1 � Z�tY Recorder
��
1 as of I Mortgage I ConttaG iiWeMednrss unpaid as d I Is Ne aPP��t tha sde
date o/ app6mtion legal a epuitade axner/
❑ Yes ❑ No
If owne0 wiN someone other than spouse. ind'wate with hiqm
IS C�C plOpEtl`/ 1f1 QIICSIIM: M(IUBP/ ASSCSSEE
❑ Real ProPenY ❑ ��Y �
ll1':11V�I' V�.aS V� ��.....
CardNO. `�z'E'9 7
� /���600, W
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/orc
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20 _ 20 _ 20 _ 20 _ 2b _ 20 _ 2(1 _
Sig�nue W Camd AuOitor Caunry Oate (nmth, daY. Y��
I/ We certify uMer Ihe penalry o( perjury that Ne above arW foregoing infortnalion is true and corteG arM Nat the applirant is a resident o( IrM'�ana and
own I contracc 6uyer of the aforemer�troned property on date application is filed.
( � ryp OQ ' j Date (rtiorW. daY• Y��i
�-� i\�P\n w � Q��
'FWltevtler�� aGdress o7 auOGrant (num6er arN stree4 �; s7ate. eM LP ootle)
Peisan auifw�iized Dy duly G�2wteE Paw¢� of Nttomay rn Cy If: 61. i-12-0. /
AOdress M auCmrtred person (wmberaiN sbeeL �: sbte. en0 ZIP mde)
Date (monN. daY. Y��)