HomeMy WebLinkAboutMortgage_Gentry (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County
FOR DEDUCTION FROM ASSESSED VALUATION F TTII ,�i State Form 43709(RH/6-09)
4 Prescribed by Department of Local Government Finance
File Mark •
INSTRUCTIONS: A 6 P r - I .
Form 1:. ,
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought i! cou•ty •i •
2) Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months kit .frRr�ji . ,er
before March 31 of each year the deduction is sought -t'
GIB. • . • . • : • • -
See reverse side for additional instructions and qualifications.
Applicant(owner or contract b restrictions on reverse side)
r
C:h 547-3phei K (14-r.-4 and m/.'nrda Cl JJl7;k
T IIC�-ed%a-6s Ooo-00-7{ ,- a01 2 I - P 1numb
,number
Assessed value of real property of /Contract Indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
Mardi 1,current year March 1,artem date ofaapplication legal or equitable avne(1
aiY7. co o J, Coo. to ® Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than vprwe,indicate with whom
It name on rend is different than that of applicant.Indicate below: Is the property in question:Annually Assessed
®Real Property ❑AnnuallyAssessed
Motile Home(IC 6-1.1-7)
Name of mortgagee or contract seller //�� //11
GQA-n-lff AIYIPri CC. t_rc)3f C.cy f
Address of mortgagee or contract seller(number and street,city state,and ZIP rode)
-111 (Ciro Si, PO P,ox ,tc) • „rate( T10 t-/7S47- 03ce.-0
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any other I If yes,what county? I What Taring District? Has this deduction been requested on property
county in Indiana? ❑ Yes ®..1 _--_ - - _ _. __1l_.��h�_�7 for current year? ❑ Yes
�. 4� D ❑ No
Deduction approved In the amount of: Drawer N O
20 20 Card NO. 20 2,9
Signature of County Auditor 13— 19 9d Date(month,day,year)
I/We certify under the penalty of perjury,. .........................e.....e...-.b.�..on anu wren(and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
Signatu. (. -rs tut name Date(month,day,yea?
Full A. - ress of app!' t(nun4r a l , et,dty,sta e,and ZIP code) ,j!2/7-C)/3
f 2 /co c iq /-41,x"" /^-- ` 26 70.
. 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)