HomeMy WebLinkAboutMortgage_Zenthoefer fa .4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
Ait GiFOR DEDUCTION FROM ASSESSED VALUATION ////5
State Form 43109(R11/01-09) 7 .
Pr scribed try Department of Local Government Finance
File Mark
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. Form filed with:
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought"
2) Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)months �edr�
before March 31 of each year the deduction is sought C +n
See reverse side for additional instructions and qualifications.
[' owner or contract buyer- restrictions on m side) DEC 3 238 en
Ta" istrict ben/ tlesaiplion .. • ben Rag number
�b/9-02/ _ 26e - t0„? .31, ,-off
Assessed value of real propeny as of Mortgage/Gonna indebtedness unpaid as of Mortgage I Contact rode. .. r_.:....t...,a ID —,.
March t.current year March 1,current year date of ap �•
/5�� ❑ 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
i)iiReaI Property ❑Annually Assessed
Name Mobile Horne.(C 6-1.1-7)∎ RrOJL ��u // ^( 922Ve/go4/11Yn7
' a tp
Address agee
or contract seller(number and street city,state.and ZIP code)
Name of assignee or other owner or hider of mortgage
ice__
Address of assignee(number and street,city.stale,and ZIP code)
Dees applicant own property in any other If yes,what county? What Taxing District? '
county in Indiana?
❑ Yes ❑ No Drawer NO...................
NI' 07J- 3 -/o /ae.
COUNTY AUDITOR 3Q '
Deduction approved in the amount of: Card NO.
20 20 20 20 _ 20 I _- I N
Signs re diAnew r County Date(month,day,year)
of County/w
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/contract buyer of the aforementioned property on date application is filed.
V Signature(�(oownerrtsfo0 na(mee)r){_2 Date(month,day,year)
'V\x Full resident address of pat9nt(number and 4 city,state,and ZIP code)
79901 S aOOE Fork 3cayycjy, s/v 47(04 $
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 rid state,and ZIP code)