HomeMy WebLinkAboutMortgage_Simpson (5)STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VAIUATION Coun Township Ye:
S M� / State Fortn 43709 (RS / 4-03) . , �
� P2saiDetl Dy Depanment of Local Govemment Finance
.y�' h i� I�
INSTRUCTIONS: ' g ry)�File Ma'rk �� �
To be filed in person or 6y mail with the County Audito� of the county where t6e propeRy is located. ��° `� �
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 0l the year the deduction rs lo be e/%c,6i�ay� 1 d 'n n
2) Mobile Homes assessed under IC 6• 1.1-7: Between January 15 and March 2 of the year the deduction4e�t�6e eNective.
See reverse side for additional instructions and quali�cations. �� . ��
orcontract buy r- see restrictions on rever si e '
� �� �
.� �}� � Key number / legal description
� C�°cG;J CCL �1 v� .�"�
d number w , �+�
/1 � / �/ �fl��Q �_� Page number - � � -
K. Q lJ �
As essed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curcent year March 1, current year owner? ❑ Yes ❑ No
(� a,oe�o
Ii no, what is his / her exact share of interest?
If name on record is different than that ot applicanl, indicate below:
iame of mortgagee or wntrad seller j �
/
Address of mortgagee or contract seller (number a s �eet, city, s
Name of assignee or other owner or holder of mortgage
Address of assignee (numbe�and street, city, etate, ZIP code)
If owned with someone other than spouse, indicate with whom.
Does applicant own property in any other i If yes, what couniy? 1M�ai Taxing Distrid?
county in Indiana? I
I
/' :OUNTY AUDITOR
Deduction Drawer N�. �•4•••�'•"'/�
zo(�r CardNO ...................... .o�7
� f_
iignature County Auditor
zo
Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-
Has this deduction been requested on
property for current year? n Yes � No
�
Date
zo
/ We certify under the penalty of perjury that the above and toregoin�� information is true and correct and thal the applicants was / were
� resident of Indiana and owner of the aforementioned property on March i, 20
��gn/atu�re (owne�s /lul�l na.me)��,/,/�� Person authorized by duly executed Power of Attomey
�/Y5 00 �. 1/ � U.�i.2,�i�� // or by IC 6-1.1-12-.07
address
-/�
U�
�
ofauthorized person