HomeMy WebLinkAboutMortgage_Bemis STATEMENT OF MORTGAGE OR CONTRACT IND DI ,BS� County Township Year
�y �%
„}iii FOR DEDUCTION FROM ASSESSED VALU
State Form 43709(R71/6-09) �7
Prescribed by Department of Lod Government Pinata TO
c(1� 9 File Mark
INSTRUCTIONS: J`` Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the pmt Air• .tech?,
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. 11 A VQ\I-- R, County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property Must file du'iL,.iii -- •j(lIfmonths
before March 31 of each year the deduction is sought - Co County Recorder
See reverse side for additional instructions and qualifications. GO-
di
Applicant owner or contract buyer see restrirdoos on reverse side)
Taxing 0 if/J`(y� Key number/legal description -Record number Page number
Thant aG -lSr-a3 /a6 0o0-2a j -0RI a0/ 3 33F1.3
Assessed value of real property as of Mortgage/Gentract indebtedness unpaid as of Mortgage l Comae t indebtedness unpaid as of Is me applicant the sole
March 1,current year Mardi t,current year date of application legal or equitable ovmM
F5 00C) ❑ 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 afferent than that of applicant indicate below. Is the property in questiorrt Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
•
Name of mortgagee or contract seller ....3 _
Address of mortgagee or contract saber(number and street city,state,and ZIP code)
Drawer NO. C.I. ...
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,nay,state,and ZIP code) Card NO. .q
s--3
Does applicant own property in any other If yes,what county? - ply
county in Indiana? ❑ Yes ❑ No
No
167L- / 1 A'//IO 3-3-// COUNTY AUDITOR /, a g
Deduction approved In the amount at.
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.
Signar/ (owners rub named Date(month,day,year)
�Jyy`Y^"„t1� ?- 9- /3
�JFFull resident -.7�apparent(number and street city,state,and ZIP code)
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street oily,state,and ZIP code)