HomeMy WebLinkAboutMortgage_Bastain.P°�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Farm 43709 (R8 / 2-07)
�' � r presrnbed by Department d Local Govemment Finance
INS7RUCTIONS:
To be filed in person w by mad wrfh fhe CountyAuditor o/ the county where the property is located.
Fding Dates: i) Real Property: Dunng the 12 months befwe June 17 0/ the year the deducGon is to be e/fecGve.
2) Mobite Homes assessed under IC 61.1-7: Behveen January 15 and Marctr 2 0( fhe year fhe deducGo�� � 6� @�e�5�
See reverse side (or additional instructions ard qualifications.
p,pplica ( gc � -see re" reverse si . ~ 6� �/3<�
V (/
T' D strict K m�m6er / legal tlesaiplion Remrd number
�� . � - as�
Asessed value ol r� popaly as of Mardi 1. arret4 year Morigage / Coniract iMeWedness unpaid as of March 1, is Ihe applimnt Ihe sde legal w equilade owneR
his / her exaa sFare
Name of rtar�gagee ar conUact seller
/
Address of mortgagee w conlrad seller
below:
sheef. dty.
Name of asagnee w ottrer ow�r or hWtler of martgage
Address of asvg�e (numbu arid sGeel. dty, slafe, arM ZIP code)
own popeRy in arry dher
a?
❑Yes ❑ No
Deduction
zo 0
I I we certiry
❑Yes ❑No
If owned with someane dher ihan spouu,'uWicale wilh whom.
�. -oa�
Is lhe property in question:
❑ Real Prooertv ❑ Mobile Hmne (IC 61.7
..•�-'-r�-w� pisUicl7
requested on property
—�...:s ❑ No
couNrv Dra�t�er i\'O.q� p ��! _�� 9�
amount of: � � � � � "
Card \'O . .................
zo _ zo _ zo _ .. . , zo —
� Caunry )
�Epenalry of perjury that Ne above and faegoing information is true and correct and tlial the applinnis was ! were a resident of
n� aforementioned property on March 7, 20
�� Date (rrimN, day, yea�
S;id �addres4 applicant (num6er and street ci(y. sfate, arM ZIP w
� �� S f � HC �N
Person aullarized 6y duly enealed Power of Allwney or by IC 61.7-12-.07
Address of aultror¢ed person (numbei arM sGee{ city. slate, arM LP mde)
Oate (rtanfh, day. yea�