HomeMy WebLinkAboutMortgage_Burst (2) �,} STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
'• State Form 43709(R11/6-09) I
�t Presoibed by Department of Local Government Finance g I
gaYJ File Mark
INSTRUCTIONS:
To be hied in person or by mail with the County Auditor or County Re of the county svbpmyIe property is located. F filed with:
Dates: 1) Real Property Must file during the year for which the deduction i tle {.V 1'
2) Mobile/Manufactured Homes not assessed as Real Property. 35 during the twer County Auditor
before March 31 of each (12)months
year the deduction is sought. • County Recorder
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See reverse side for additional instructions and qualifications. #Z' pfj OR•Appnnt(owner or co buyer-see fe on re side)!p� II4GOuNj1 AV
ns Ail am FardDistrict Key number, Ption-a 57/ 7 Record
Assessed value of real property as of _Morttgage I 3 `- 601 uW/'of minrk age ICC�indebtedness unpaid as of Is the appicant the Contract indebtedness Marsh 1,aims year March I,arrem date of application legal or equitable owner?
/rgdOQ I ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applcant,indicate below Is the property in question:Annually Assessed
C tie I Property ❑Annually Assessed
• . Mobile Home(IC 6-l.1-7)
Name of mortgagee or contract seller Alb(J� _
Address of mortgagee or contract seller((/��number and street,city,ate,and ZIP code)
Name of assignee or other owner or holder of mortgage C �r '7
Address of assignee(number and street aY.state,and ZIP code)
(�; I ti5/ r �������/ )�
I fI NYcl
Does applicant own property in any other If yes,what county? What Taxing Di
county in Indiana? ❑ Yes
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
Sjgnatxre(owner's MU nna,�mme)yl /�J`�L') Date(month,day,year)
}I C ` t'dd ofd pficont numbers a 0nd ZIP cede)
L 1 l �fIC-r aX [ 1r 11 l\ '1 1, '-
Person authorized by duly executed Power of Atmrrme or by IC 631.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet,city,state,and ZIP code) N\
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