HomeMy WebLinkAboutMortgage_Ortiz^�� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
__ , FOR DEDUCTION FROM ASSESSED VALUATION
Sfate fwm 93709 (R77 / 6-09)
\ ? Presai0ed by DepartmeM of Laral Govemment Fnance
Coun Township Year
de a
�wsrRUCnoNS:
To 6e filed in person w by mail wifh the CountyAUditor or Counry Recorde� o/ tAe counry whem fhe property is focated.
Fi(irg Dates: i) Real Property: Must file durirg the year for which the deduction is sough[.
2) Mobde / ManufaUUred Homes rrot assessed as Real Property Must file dunng the twelve (12) rtwnths
before Ma�ch 31 of each year the deduc7ion is sought.
See reverse side (or addRional insvuctions arM quali�cations.
,, Appbcantlowxr ormi�Va bN"�r- see msLir�ons m rere+sp.SbCl ..
�� �
Assessed rdue aF 2a1 popertY as W
MarU 1, na�en[ yrar
F""'��90'G 2 S 2011
�{ CountyAUditw
I__I ��^�'d�
�8�'ao3- �Ioa. �ob-oa8 I �o;,
�1pr�Gage/ Conbaa intlebteCness unpaid as of Mwtg� ��� uWehtedness unpaid as d Is�Ne
Marrh 1. a1�^�� iwT�
If ro. wha� R his / her exaG share ot interest?
It iwrie on mmN is Eilterent ihan chat ot aPplicant, uMinte belm
Name of n»n9agee or mntraU seller
Address M�rort9a9ce ar mntract se0er (numbe� and st+ee4 �4Y.
Name of assignee a other owner or holder W mortgage
Adtlress of assgnce (number and streef, tlry, s/ate, antl Z/P catl�
Dces epplicam wm yoperty in any oNer If yes, w
county in Indera? ❑ Yes
❑ Na
Deduction approved in ihe amount of:
20 � 20 _ � 20
AuEiiw
H owned wiUi someone ather �han spouse. indimte wrth wham
Wtal Ta
COUNTYAUOROR
20 20
Counry
Yes ❑ No
Is Me propmty in Vu�tion: MfwaM fvssesud
❑ Real PropeKY ❑ MnuaAY 0.�sed
Moble F�lome (IC 61.7-7)
Di•a�►•er NO.......(d„Q,�.�
.....
Card NO. ......� � 5 �1
5o.��,aS � ........
�F'���:�7
I I We certify uMU Ne penalty of perjury that Ne above arW (oregdng infwmation is We and correct arW that the aDW�mnt is a resident of Intliana aM
wnVacl buyer of the aforementioned property on date application is filed.
� re(ow99's !uU �ame)/ � Date (monN, day, Yaa�
Person aul7araeE �y dWy
ZlPCOtle)
(numbera� street u1Y, stafe, ard LP mtle)
� I�w. �Y r�