HomeMy WebLinkAboutMortgage_Block STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATIO I I- -•' State Forth 43709(R71/6-09)
Prescribed by Department of Local Government Finance ®A` Flle Mark
INSTRUCTIONS: ff1y CC((`` pp C 7 fP11''77 Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the county wherW W8 pl2pfrtjZV btated.l
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought i unry Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must Re during a twelve 12) I ❑ County Reorder
before March 31 of each year the deduction is sought
See reverse side for itional instructions a qualifications. �/_ �/,GIBSONN C�OOUyN`TTYY/AUDITOR
Applicant(owner or tract buye -L.-. � e) l� U.h �.f lCC)cyr
Ta ( _ � /a-36—description '70 3-o0c /33 �Sy Key
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract bdebtedness unpaid as of Is de«p*rant New
March 1,current year Marti 1.an r�O o date of application I 0 Yes ❑ No
lino,what b his/her exact share of interest? rte/„I ( It 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
❑Real Property ❑Annually Assessed
• I Mobile Home(IC 6x1.1-7)
Name of mortgagee or contract seller S �7
Address of mortgagee or contract seller(number and street state,and ZIP code)
Name of assignee or other owner or holder of mortgage
--
Address of a•^---
Does applica I What Taxing District? for current year? been requested m property
minty in lMi ' aiii 4 I ❑ yes ❑ No
'NTY AUDITOR
Decludien ape /.3 6 54
20,,,, cu 20 20 20
Sigreoae of Camry
County Date(month,day,tear)
I/We rtify under the penalty of perjury that the above and foregoing information is true and correct and that the:appli(ant is a resident of Indiana and
owner I contract buyer of the aforemention property on date application is filed.
Iture(owners nacre) I f Date(� ,day,year)
FtN resides of appo and£dandt;- any,state,and ZIP code) �1
e
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-02 r I Date(month,day,year)
Address of authorized person (number and street city,stare.and ZIP code)