HomeMy WebLinkAboutMortgage_HueyR`n STATEMENT OF MORTGAGE OR CONTRACT�� T;�DN�S Coun Township vear
FOR DEDUCTION FROM ASSESSED VALUA�iO�J� �LJ g�
� State Fwm 43709 (R71 / 609)
� � PrPSaibed by �epartmerH of Local Govemmenl Flrance FEB 2 4 2012
µ File Mark
�NSTRUCTIONS: C �
Fwm fli eC with:
To 6e fiied in person o� by mail with !he County Auditor or Counry RewNer o/ the county where the ropeRy is located.
F�7irg Dates: i) Real Pmperty: Must file durirg the year lor which !he deduclion is sought. V Counry Auditor
2) Mo6iie / Manulactured Homes not assessed as Real Propert fiAai$�Hp Qpj � � al�onths
6efore March 31 of each year the deduction is sought. ��� Counry Remrder
See reverse side for additional instnictwns and qualifications.
AppGrant(owner buyer- ns verse ) �/'�
Y��
T �' f1 KeY l.`'O'� I a�elo' � O�t/1 �• �O U`^"� RemN n bPi Page numDrl
As¢ssed value d real property as o( Mortgage / Conpaa indebted�ress unpaid as W Martgage / Cmnafl uWebtedness un7aiE az d is Ne aVV�imn� the
Martii 1. axmnt �ear Martl� 1. aurel[C�eac I� OO � date of aVP���^ �' n Y2,e ❑ ON
v i�
If no, what is ha ! her e�rt share
Ii �rrie m rt.mE is dMerent than Nat o( aPpfwant, mEibte telmr.
Name of mort�agee w contraU seller
or contrad se0er (num6er arN sbeei, ciry, sfate,
awner w
Address of as.vgnee (number and st2et, tlry, sfate. an0 ZIP mEe)
Oce5 appli�n[ oxn pfoperty in any otlier
counry in IrWana?
❑ Yes ❑ No
�
Deduclion approved'm tlre amount of:
20 20
sig�ature ot Camh nwitw
If yes. what munty?
20 I 20
sortieofre
NRat Tadng Disincl?
20
sPWSe.
Is the WopertY in Vuestion: Mnue�y AssesseC
❑ R�� ���v O �N �
MoMle Hame (IC 6
Has Uiis de0uction been reQUeSteE m P�Y
far arrern Year ❑ Yes ❑
20 � 20
I/ We certify under the penatty of pe�ury that Ne above and foregoing infomialion is true and cortect and ihat the applinnt is a resident of I�iana aM
owner / mntracf buyer of ihe aforemenUOned property on date appl'ralion is filed.
3rew¢'{�vnefs fi� rama) �/ �/ Date (rtionN, daY lear)
w
P4dress o( auttror¢ed person (num0er aM sbce; �y, sfate, antl LP mde)
Dafe (rtnnfh, daY, Y��