HomeMy WebLinkAboutMortgage_Burger (5)� STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� µ� ! Sta'e Fortn 43709 (R5 / 4-03)
Prescribed by Departmcnt of Local Govemment Financa 5
� I����
INS7RUCTIONS: �� File Mark
To be filed in person or by mail with ihe Counry Auditor ol the county where the propeRy is located.
Filing Dates: 1J Real Property. Dunng the 12 months belore May 11 of the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year fhe deduction is to be effective.
See 2verse side /or additional instructions and qualificafions.
Appticant
District
Assessed value of real property
March 1, current year
If no, whai is
name on
/�see restrict)�prys
/ O /) /A C�
exact share of interest?
'I �' I VJ —VV I•
cord is different than that of
of mortgagee or contract seller
side)
Key number / legal description
Mortgage / Contrad ii
March 1, nent year
�i7i
below:
Record number
Page number
unpaid as of ( Is the applicant the sole legal or equitable
owne(? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom. -
of mortgagee or cont�ad selier (number and st2et, city, state,
or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP
Does applipnt own property in any other If yes, what county?
county in Indiana?
20 �
P
Signature
approve� � �
`�/"J�
r �s-��9�
County Auditor
What Taxing District?
Y AUDITOR
20
�l
property in question:
❑ Mobile Hortie QC 61.1-�
Has this dedudion been requested on
propertyforcunentyeaf?� Yes❑ No
�
Date
20
certify under the penalty of perjury lhat the above and foregoing informalion is true and corred and that the applicants was / were
lent of Indiana and owner of lhe aforementioned properiy on March t, 20
full name)
Person authorized by duly execuled Power of Attorney
or by IC 6-1.1-12-.07
=u1! residB�N �ddre�s of applipnt Address of authorized person
�/o6y A,��e La.�� ���z��� L�•