HomeMy WebLinkAboutMortgage_Roth ��. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
-; FOR DEDUCTION FROM ASSESSED VALUATION
t" State Form 43709(R11/6-09) -•7�'
-s Prescribed by Department of Loral Government Finance FI ryg,yy�Z
INSTRUCTIONS:
To be tiled in person or by mail with the County Auditor or County Recorder of the county where the property is located. Form coed with.
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. ty Auditor
M�,R �-��,
2) Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months
before March 31 of each year the deduction is sought. ❑ County Recorder
See reverse side far additional instructions and qualifications. 1 y IT-/-/P/Dili
Apron weer or c o n t r a c t r-serricc&ns on -•- -side) • ' • I ` fY AUDITOR
Tan District Key number I al description Record number Page number
e��� 026- //._ /3 - .moo? -000. o69- 0 d. 7 '(951
Assessed value of real property Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
March 1,aarent year March I,current year data of application legal or equitable owner?
109o00 ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than sdouse,indicate with whom
If name on record is different than that of applicant indicate below. Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller Tel
Address of mortgagee or contract seller(number and street,city state,and ZIP code)code) - -
Name of assignee or other owner or holder of mortgage tr/�'1l - /I�, {�-rf
Addr/a�ygsq/qf assignee(number and street,city,state,and ZIP code) ' / DT )' —
Does appli nt own property in any other If yes,what county? What Taxing District / /7 Z—/q6/
county in Indiana? -
❑ Yes ❑ No O
COUNTY AUDITOR
Deduction approved in the amount of.
20 20 20 20 20 20 20
Signature (Co County i Date(rtonth,daY.year)
I I We certify under •nalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract b r of e aforementioned property on date application is filed.
\ Si9na (owneh -Z- Daar)
Full resident address_o .ppl.-nt(nu r rd et•city,state,and ZIP code)
pia S- 'a /al- j i /. p,riivcc J V %/967e,
Person authorized b uy executed Power of Astomne9 or by IC 6-1.1-12-0.7 Date(month,day,year)
iNlk
Address of authorized person (number and sheet,city,state,and ZIP code)