HomeMy WebLinkAboutMortgage_Cox (11) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS C T 1 Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(RI1/6-09)
Prescnbed by Department of Local Government Finance
f.. e
FR:-
INSTRUCTIONS: AP t I I a
To be filed in person or by mad with the County Auditor or County Recorder of the county where the property is located FonnNed with
d.
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought 4; Auditor Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months /1 ; •11-111111771r;
before March 31 of each year the deduction is sought - It' y htelCer•
See reverse side for additional instructions and qualifications.
GIBSON. Oil
Applicant( r or conlravyer-see restrictions on raversaee)
Taxing - Vict K���/1V'I 4 AD ca b Q-15 O( (6,c2 Oi_ 3 n Record number Page number legal description
Assessed value of real property as of e/Contact i debtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
Mardi 1.anent year March I,aurent y'e-tar date of application legal or equitable owner?
I b DO ❑ No
If no,what is he his/h exact share of interest? ) If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant.indicate below Er4operty in question:Annually Assessed
Property ❑Annually Assessed
Mobie Home(IC 6-1.1-7)
Name of coo r contract seller --® ' rrSy 0
Address of mortgagee r contract seder(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee /
ssignee(number and street,tlry,state,and ZIP code) /
Does applicant own property in any other If yes,what county? What Taxing District? d sfed on property
county in Indiana? �--,.) /1
❑ yes 6JrNo , fin( l�I, (,�/ Yes ❑ No
l COUt-- v ' 1�" Ci� I /
Deduction approved in the amount ot: IA-1 I i I S
20 20 20 20 _ 20
Signature of County Auditor - C Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing informatia...true and correct and that the applicant is a resident of Indiana and
owner/contact buyer of the aforemention property on date application is filed.
Signature o �'`'''nanre) J Data(month,day,Yew/
f tr erR 1 1 �/ ✓t- d treet,. •, and
...x� y�
Ip1 171 of
) A) C9A-Vt biz C \� 'p 1/J —G1 L.c o
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code) `{si