Mortgage_Hollingsworth aft STATEMENT OF MORTGAGE OR CONTRACT FEIltlff' younty Township Y,$ar
�a` yy FOR DEDUCTION FROM ASSESSED VALUATIIOON `I
State Form 43709(R77/609) 0\0
pnesaibed by Deparhnent of Loral Govemmenl Finance DEC 2 2013 File Mark ,`
STRUCnONS:
Form bled with:
be filed in person or by mail with the County Auditor or County Recorder of the coun . ere th ra pro rain ' • .ted.
Filing Dates: f) Real Property Must file during the year for which the deduction is •••14.• -frig County Auditor
2) Mobile/Manufactured Homes not assessed as Real Propertz se cm tee It ir.a•, nd
61Ro the County Recorder ID before March 31 of each year the deduction is sought D)T
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•
See reverse _ nstructbru and qualifications.
ApPGmn( _ SII -.!mast onre` /" , •s AIll.At.- A1 •
Ta ei Key number/legal desaipbon r Fj�a�tl nurtlpe< Page n
/ //l orb-/�7-(103-r}I��,n3• 005'- a X67
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of I Mortgage I Conaaa indebtedness unpaid as of Is the applicant the sole
Marts 1,aamfrt year March 1,current I date of application legal or equitable owner?
❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with vdnm
If name on record is afferent than that at applicant indicate below: Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
aMobile Home(IC 6-1.1-7)
Name of mortgagee ///n(J() M,(,J
Address of mortgagee or contract seller(number and street city,state,and ZIP coder
Name of assignee or other owner or holder of mortgage f
F --•--`-•-••^°^■•e_newt stare,and ZIP�rode)�
C 'Linty? •� What Taxing District? Has Rsndedducion been requested on property .
Drawer No...€t1 .. ❑ Yes ❑ No -
Card NO. ...6107117--
. 0711 COUNTY AUDITOR
•
_ 20 20 20 20
.1,4•01:'af L .ty Aid •/ :71/e County Date(month,day,year)
ge
I/We certify under the penalty o perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
\/eigl/n��\�y���/(�o�jvzers name)",- / Date(month,day,year)
Full resident address of a nt( r and/'!teeet.,�\ry,state and ZIP code)
. to Ws S ,Q.nn; , P(;Mp+ f' 4-?lam
Person authorized by duly executed Power of ey or by IC 6-1.1-12-0. Date(month,day.year)
Address of authorized person (number and street city,sate,and ZIP code) .