HomeMy WebLinkAboutMortgage_Douglas^'n STATEMENT OF MORTCaAGE OR CONTRACT INDEBTEDNES� Coun 7ownship Year
__ :. FOR DEDUCTION FROM ASSESSED VALUATION �i
� State Fwm 43709 (Ri t/ 6-09) ^
�,,,, P�esai0ed by �eP��M of Laml GovemmeN Friarice , Q
� ,O File Mark
�STRUCTIONS: �
Fortn Aed wBh:
To be filed in person w by mail with tha CountyAuditw or Counry Recwder o7 the counry where Ne property is locafed.
Fi/irg Dates: 1) Real Pmperry: Must file durirg the year for which the deduction is wught � County Auditw
2J MobAe / Manu/auu2d Hanes rat assessed as Real Property Must file during the fweNe (12J monfhs
before March 37 01 each year the deduction is sought ❑ County Remrdu
See 2verse sida 7or atldifional instruUions and qualificafeons.
AppGtant (owner or oontraU buyer- see resfi'raons m
ITaring Du�tnrl Cey nunber / k,
� A
AttessedveWedmalproprJtyad Mwt
Mert'h 1, qaRnl yG3f M3n
If �q. whal is his ! trer exaC share of intere5t?
If name m mmN s CiRerent than Nat ol app6mn; mGUate below:
Name of rtrortgagee or mntrarl seller
anar� a roon� «�,o-aa
- vv �7 � oco
'udebteCness unvaid as ot Mortgage / l',ono-act i�Mebtedr�ess unv� as d Is Me aPD�� tlre sde
r aate of applkatian legal w eQuibde oxme(t
❑ Yes ❑ No
If owned wiN someorie other Ihan spouse. iMimte wiN whom
5ate, and LP coda)
�f assignea (numDer aM stree4 �y. slare, and Z/P tode)
limnt own pmperty in any oNer It yes. what
i�ag�aa
❑ Yes ❑ No
W�at
15 Ihe ProP�Y in Guestion: M�waq' Pssei5e0
❑ Rea� Ropenr ❑ nnnua�y wssessed
rw a,�,n vean
requesteE m property
Yes LJ No
COUNTYAUDROR
Or�uction apprwed m Ne amount of:
20 20 _ 20 _ 20 20 _ 20 _ 20 _
Sigrenrte d CamN nWhor Counry Da�e (rtronRr. daY Y�e�
I/ We certify under the penalry of perjury that Ne above and fomgoing infortnatlon is W e and corrert ard 1ha[ ihe appli�ant is a resident of InEiana aM
amer I contrad buyer of Ne a(o2merrtioned property on date application is filed.
re (ownefs /utl name) Date (m�nlh�day, yaa — /1
'"" i O�
Full revdent d a t(numDe� and sbee4 tlry, slate, and ZIP code)
Person aNhorrzed Gy tlWy ezewied Pow�er d AtlomeY a M IC 61.1-12-0.7 �(�+. �Y. Y��
Pddress of authaved person (numGer arM strcet clry, sbte. aM ZIP code)