HomeMy WebLinkAboutMortgage_Poling"'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun�
_ : FOR DEDUCTION FROM ASSESSED VALUATION
� � StateFortn43709(R1116-W)
S,.,. � Presrnbed by DepartrtieN of Laml Go`emmerrt Firence
INSTRUC710NS:
To 6e fiied in person w by mail with the CountyAuditor or Counry Recorder of the counry where the pmperty is loca .
FiNng Dates: 1J Real Property: Must fi!e durrrg the yrear Por which the deduction is sought.
2) Mob�7e / Manufectured Homes not assessed as Real Pruperty Must file dunng fhe hveNe (72) months
befwe Maich 37 o{each yeer Ne deduclion is sought.
See 2verse side tor addtional inshucGOns arM qualifications. �
,�,�d�,�,��
Marrh t, arma year
If rw, wha� b ha I her e�d shara o'�
tt`wrre m remtl a d.Ruent than B
� Counry A� mr
V � C2UJ4lRecorder
� a-o � - d� _odi OQ� -oaz � � .._..�o T. ��
�1p�p�ge / Contraa 4W�tedr�s unpaid as d Abrigage / Contrao cWebbbjjj���d�ssss unpat0 as d Is ihe eppG�ant the sale
Mard� t, wrtent Y� date of ePP�� ���v� � a eWi1a61e ownM
� [ L A_J ❑ Yes ❑ No
Name of rtnrtgagee w mnvaU u4er
� �
Aildress d rtnrtgaqee ar mntraG srAer (n� and sfi
Name ol as5ignea or oUtrl axner w holder of mortgage
Mtlress ot assignee (number eM atree4 mY• state, entl
ooes eppi�m a�m wovenY
couiLLy m Intliana? �
Deduami app�w� m tlre amount oE
�
ciy, state. aM Z/P code)
muny?
someorie dher Ihan spouse. U�tli�te wtN wMm
is tlM P�OertY in Que5lia�: MrweDy 0.ssessed
� Real Pmperty Q Mnually Assessed
Mob�e Fiome (IC 61.
WhatTad(g D'atrirl
COUNTYAUDROR
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Dl•a�VCY 1�•..
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20 _ 20 _ 20 _ 20 20 _ YO _
SigreNre of Camb Auditw Caunb Dete (rmW. EaY. Y��
1 I We certify ulWer the penalry of perjury that the above and (oregoing infomiation is true and correct and that Ne applirant is a resident of Iridiare aiM
owner I mntrad buyer ot the aforementbned properry on date appliption is filed.
SlgndGUe (ownarE fiID+Y+Pre) /I .. Date (monfi. daY. Y��
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sbeet u11A�te. and
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oa�e t�nn. dar. r�
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