HomeMy WebLinkAboutMortgage_Campisi��� � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION Count nshi Ye
'. � w �y Stale Fwm 43709 (R6I 5-06)
� Presaibed by Department of loral Gwemment Finance
INSTRUCTIONS: Ej10 Mark ��
To be Cled in person or by mail with the County Auditor of the county where the property is located. e���
Filing Dates: 1) Real Property: Dunng the 12 months befoie June I1 of the year the deduction is to be elfecti��SC�N C,OUN7Y AUDITOR
2J Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 and Ma�ch 2 of the year the e uc �on �s to be eHective.
See reverse side for additional instructions and quali/ications.
P.ppl' nl (owner or conhact buyer- see restrictions on reversel s�id.,e^) �
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axing Distrid Key number / legal description Record number •� v a�p
-/7 � -3/ - � Q� - DOC), d o
�a 3 Y-o �/ Page number ��
Assessed val af real pr erty as of MoAgage / Contrect indebtedness unpaid as of Is the applicant the sole legal or equitable
March i, currenl year March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than ihat of applicanl, indicate below: Is lhe property in question:
0 Real Property ❑ Mobile Hmie QC 61.1-�
�e of mortgagee or contrad seller � _ .
Address of mortgagee or conUact seiler (nu�r and st2et, city, state, ZIP ��f
Dra�}�er NO. °1��.(�,'.. ��,?,3
_ ,.
, � � � .
Name of assignee or other owner or holder of mortgage
C rd�\`O. .......
..............
Address of assignee (number and street, ciry, state, ZIP code) ��, �Q� , O O
Does applicant own property in any other If yes, what county? What Taxing District? � Has this dedudion been requested on
county in Indiana? property for current yeaf?Q Yes� No
COUNTY AUDITOR
Dedudion approved in the amounl of:
20 _� 20 �_ 20 20 20 20 20
� �
Signature County Audilor Date
We certify under the penalty of perjury that the above and foregoing infortnation is true and corzed and that the applicants was / were
sident of Indiana and owner of the aforemenlioned property on March 1, 20
� g ture (owne/s me) Person authorized by duty executed Power of Atlomey
, or by IC 6-1.1-12-.07
�Full re ident addres of p cant Address oi authorized person
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