HomeMy WebLinkAboutMortgage_Fortner^� STATEMENT OF MORTGAGE OR CONTRACT INDE
_. = FOR DEDUCTION FROM ASSESSED VALUATION
� Stata Fam 43709 (R71/6-09)
,,,,. Prgtri6ed by Departmertl W lnbl C»vemment Financro
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INSTRUCTIONS:
Form Aed wiCr.
To be fiied in person w 6y mail with the CounryAuditor o� Counry Recarder o/ fhe county whefe the pioperty is bcated.
R7ing Dates: 1J Real Pmperty: Musf file during the year for which Ne deduclion is soughG � �p�yty q�d��
2) Mo6Be / Manufactured Fbmes not essessed as Real Property Must file dunng Me fwefve (12J months ,GT y++
betae March 37 of eadr year the deduction is sayht Cou� Remde�
See reverse side for eddilional ins6uctiw�s amf qualificalions.
I ApDGt3q� (pW��er w tonjaC 6uvxr - se6 nstricti0r+i m/4v�'sPfilel
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If name m remrG o Stlfe2nt than Nat o! aPP��i• trMkate bebw.
Name of rtwrt9a9ee or mntracl u0er �
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AEdress d morcga9� «cantrarl seder (n a�
Name o( assignee a aha wmer w MNU of muq
Maress of aaqnee (number ard sneet �1: slEte,
Ooes epptimnt wm prapeny in any ofher
munty m Ind"mu? ❑ Yes ❑ No
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�
GIBSO ,
m d Ls Me ePP�� ihe sde
1eg31 a eQUitatle avmrYl
� ❑ Yes ❑ No
IIi awned wiN xrreone oiher Ihan spouse. ind¢ate yith wl�n
p property in 4uesDOn: MnueDy Asses,ed
— - --- - - -� �-aoveKV ❑ Armua�NAssessed
DI':l1\'CI' ��. ��� ........
Ca rd N O. ....`.�. �.��.........
If yes. what muntyt � Whal Ta�drg
� � P�RY
Yes ❑ No
COUNTYAUDROR
DeducUm approved In Ure amount of:
20 20 20 20 20 20 _ 2b _
Sig�aWre o/ Cowib Auditw Counry Da�e (month, day, Yee�
�I/ We certHy urWer the penalry of perjury Nat Ne above aM foregoing infortnalion is W e and cortecY arid that Ne applirant is a resident of IMiana aM
awner I contract buyer of the aforemenuoned property on date apdication is filed.
� re(owna/s fiA ) Date (monC�. daY• Ya�A
� up aEd�s t(numDar and sbce4 tlry, atate. ard LP aotle)
Person aufho�¢ed Oy duly teE Power of Attomay w by IC G7.1-12-0.7 Date (rtprtlA. dtY. Y�
Atltlress of aWia�ed person (numberaM saeat �: sbfa, aM 2!P cnde) .