HomeMy WebLinkAboutMortgage_Gomez i._ STATEMENT OF MORTGAGE OR CON I EB1fE0 ,t County Township Year
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FOR DEDUCTION FROM ASSESSED VTA�UA�►
State Form 43709(RI1/6-09)
Prescribed by Department of Loral Government Finance APR 15'2013 Prescribed 2013
File Mark
INSTRUC77ONS:
Form Abe with:
M be filed in person or by mail with the County Aud for or County Recorder of th .unty 1-—.4 f-property is located.
F i l i n g Dates: 1) Real Property:Must fi l e d u r i n g t h e year f o r which the deduc L 4..-. ....... .. .. .. ..... . 0 o u n t y
2)Mobile/Manufactured Homes not assessed as Real P R County Auditor
before March 31 of each year the deduction is sought L a���f r2)months ❑ County Recorder
See reverse side for additional instructions and qualifications.
Appliicannt,.(owner/or contract buyeerr1 see restrictions on reverse side) //� —
7/),uKp ? r4147y1 F/ir °F Ll �/LOTI N /092/Yt
Ta a istrict Key numdh/legal description Q Record number Page number
QZ044 Tap a to-, a -o -3oo 00 ci i 03 a a 7 o?o i 3 959
Assessed value of real profperty as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Mardi 1.current year Mahn 1,current year date of application legal or equitable owner?
/000n0 ❑ Yes ❑ No
If no,what is his/her 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 Is the property in question:Annually Assessed
SReal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee 0 tear seller — -_
Address of mortgagee or contract seller(number and street,coy state,and ZIP code) ------
T )
Name of assignee or other owner or holder of mortgage Drawer No .• O/ 3.
Address of assignee(number and street,city state,and ZIP code) .•/� //'�}•
.Does applicant own property in any other If yes,what count/? Wt Card 1��/�r{(0. ... y7� ....
county in Indiana? /'`�'/V WI l
❑ Yes ❑ NO ❑ No
COUNTYAUDITOR - .
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 f contact buyer of the aforementioned property on date application is filed.
Sig ,,(owner's name Date(month,day,year)
/, II`UKE �ol1tE2 / o�HA�oAJ I WEI�t��
Full resident address of a t(number and sheet,city,state,and Z code)
A 3 56 2r ( Zo 60(5-r Rwcerc#i, //v 5/767o
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year) t
Address of authorized person (number and street,city.state,and ZIP code) _ 1