HomeMy WebLinkAboutMortgage_Geuss (2)^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun sh r
_, FOR DEDUCTION FROM ASSESSED VALUATION
• Stale Form 43709 (R71 / 6-09)
S�.,� Presaibed by Department of Wral Govemment Fuance
�rsraucnoNS: A�'� �a�` 2012
To 6e frled in erson or b mail with [he Coun Auditor orCoun Recorder o/ fhe wun where the m F� �� ��
P Y b N N P PertYislocated. C.1 ry��
Filirg Dates: 1J Real Property: Must file during the year/or which the deduclion is soughL ��� d���
� 2) MobRe / Manufactured Homes rrof assessed as Real Properly Must fi!e dunng the fweNe (72) monfhs I�I �Ca,n \
be(oraMarch37ofeachyearthedeductioniss�u�ghL GIB N�9UIV�Y�i u� �
See reverse s�de for addilional inshuctbns arM qualfications.
�App�nt ( or oontraG bflYer- see reshirt;onspq reverse siie) /�
Asetsed vaWe d real popeM1Y as ot
Ma�h 1, br�eM year
tt ro, what is his I her e�l share of inferesl?
It name on remrd s dtlferen[ Nan
�Ba9ee or contract seller
mntraci seuer
Cer I k9al d�dxippe -
- - a3- �/. 99d- G
Mortpage / Cantract inde6tedness unpaid as o( Morigage I Contrac['uME
March 1, wrteM year date o( appGCation
C
If awrred wi�h sonieone oNer Ihan
3nl'oMicate beb�r.
��l � �
randsvee;ciry,state.anELPooOe) /
Name at atsignee v Nhu owner or holder M mpigage
(number aM atreet, ray, s7ate,
pm poperty in any oNer I If yes, wha[ count/1 I What
ia? ❑ No
❑ Yes
Deduction appovc7 rt� ihe amoum oE
20 _
sy�n,a or c�,a a�a��«
COUNTY
20 _ � 20 � 20
J%1 � ��3%�
as d Is Ihe epplirant Ne sde
legal «equdade ame!!
❑ Yes ❑ No
with �Nian .
Is Ihe pmperty in Questim: Mnua�y Assessed
❑ Reai RoperH ❑ %4mual!r Psse�d
� :��..L�..�.�...
C'l 1 (1 � � �� � . . . .
cw� ` I� �_ , a�.,,ay,res�
n prapetly
❑ No
0
I/ We certify under the penalry of perjury that Ne above arW foregoing infortnalion is We and mrtect and that the appli�ant is a resident o( Indiana aM
owner I contracl buyer of the aforementioned pmperty on date applicatlon is filed.
IPa9+Se (a�nl��) Date (monfh. daY• YgeA
FID resident adCress of app6rant (numDe�and sbee; tlry, state, a
t��oo e Q�d�pW� y s
Prlson autlror¢e0 Oy dury e.ecuced Po«er of AnomeY or M IC 61
prlsrn (numbererM sLeeR dry. sta�e, aM LP cade)
Date (manlh. Cay l��