HomeMy WebLinkAboutMortgage_Amos (3)"'n STATEMENT O ORTGAGE O CONTRACT INDEBTEDNESS Coun Township Year
- - FOR DEDUCTIORNS�r�OhR�ASS SSED VALUATION
� Sfata Fwm 43709 (R71 / 6O9)
� r Presaibetl by �epartmeM of Local Gm�emrtrent Finance
File Mark
lNSTRUCTIONS:
To 6e filed in person or by mail with the CountyAUd"ROr or Counry Recortier o/ the munry where the pmperty is bcated. F�
Fding Dates: 7) Real Property: Must fJe dunrg Ne year for whicAlhe deduction is sought. Counry �uditnr
2J Mo6de / Manutactured Hanes rrot assessed as Real Properly Musf fife dunng the twelve (12) monfhs ���� ���--.-y
be(ore Malch 31 of eacA year the deducfion is sought. ❑ Counry•v \
See reverse side /a additional instruUions and qualfications. G I BSON C 0 U NTY AU DITOR
nppfuam rcrcrntrart(rqyer�seereyartion�q6i)everseside)
a
tt ro, whal is ha / her exaG sKare of inte�esl?
It rw�re On recqtl's EiMer�t tlian that o� aOP��L bdibte Gelaw:
Name o( nnrtgagee a mntrar� seAer /j
Addrea of mort9a9� or mntraa se0 n arrTSb
Name of assignee or oMU ownet or holder ot mortgage
AdA2ss of assignee (number and sGeet ut�: slefa, and
Dces eppliont own propeM1y in any oNer
munry in IMara? ❑ Yes
DeducOOn approve0 in ihe amount
� �_
Sig(aMe W Cau�b AW imr
I/ We certify under the penalry ot
owner I contracl buyer of the afor
resitlent eddress N applmant
X �l3S E. O� �
Pelsan authofaetl �y didy exewt
person (numberarM
ss u �N
ard LP code)
�{J� �
I Con7aa u�d
(_1mos, �� A�I� 4�
� Lp NA-r����
� �8� ��a S�
ia- y��
C�J
RemN munhrl
pa�d as d Is Ne
/� le9al�
spouse, iMinte wiN x1u
IsJ� property in questic
�] Reai ProPeKY ❑
�J /
iitade axne(1
Yes ❑ No
I AssesseE
Pssessed
� nc ��.
Has �his EeOUGim Eeen re9ursted an P�Y
tw artem yeaYl ❑ Yes
❑ No
2� � 2�
IDate (rtanth. CaY. Y��
ihat the applinnt is a resident of IMiana a�
Data (monfh, day, ysa�
�Y ,��
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