HomeMy WebLinkAboutMortgage_BurgerSTATEAAENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
L�� / S�ate Fortn 43709 (RS / 4-03)
� PrescriDed by Depanment of Local Govemment Finance � jj � �� �.,
, H .!
� 11 �—/ .t1.J 1_.3'
To beRfiled�nOperson or by mail with the County Auditor of the county where the propeRy is Ioc�t�d R`Z, 2 ZOO4 Fiie Mark
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the dedu�rtion is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Belween January 15 and Mar/cli 2 0l the_yeer flie�deductron�fo be eHective.
See reverse side for additional insfructions and qualifications. /��G,3"� G.~j �''J' "'��, „�'�J i
Applicant (owne� ntract bu r- ee trictions on reverse side)
Taxing Distrid y number / legal description Record number
� O l-0/ls� � 3-557
Page number
Assessed value of real properiy as of Mortgage / Contred indebtedness unpaid as of Is the applicant th� ole legal or equitable
March 1, wrrent year March 1, wrrent year ownef? LgYes ❑ No
� �
If no, what is his / her exact share of interest? I owned with someone other lhan spouse, indicate with whom.
If name on record is different ihan tFiat of appiicant, indicate below: Is the property in question:
eal Property ❑ Mobile Home QC Fr7.1-�
�me of mortgagee or contrad seller �
P
Address of mortgagee or contrad selfer (num r and street, city, ate ZIP
Name of assignee or other owner or holder of mortgage
D� �/� -qy
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has lhis dedudion been requested on
county in Indiana? propeAy for current year? � Yes � No
COUNTY AUDITOR
Dedudion approved in the amounf of:
20 20 20 �� 20 � 20 ++xt _ 20 20
� Q � �
Signature County Auditor Date
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
S' re (owners (ull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
re ent address of applicant Address of authorized person
D �.
---- - - - � z� z� � �__._ -�_ _..