HomeMy WebLinkAboutMortgage_Cook (5) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Court I
w` dr FOR DEDUCTION FROM ASSESSED VALUATION ��`�
�t -�5�'J State Form 43709(R11/6-09)
k� y-r''9 Presrnbed by Department of Local Government Finance LU'4
INSTRUCTIONS: F with.
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.
Fling 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 i BS N 9)ueuxoci so R
before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
- or contact byee . . on rare %•)•Taxi - I' I •en C) or _rd l.. •iaJ - w a s20. _00.71 ,/3r P na/v
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the appMant the sole
Mardi 1,arena year March 1,anent year date of apprrwtion // legal or equitable owner?
/� uUo ❑ Yes ❑ No
tf no,what is his/her exact sham of interest? If owned with someone other than spouse,indicate with whom
If name on record is diiemnt than that of appacant Indicate below. lf-�'pa�e property in question:Annually Assessed
LU("eal Property ❑AnnuallyAssessed
//�-f�/' ,.//'(164/444- (� Motile Horne QC&-1.1-7)
Name of mortgagee or contract seller // - A�/� G{/ -
Address of mortgagee or contract seller(number and street,ciiy,state,and ZIP rU/�/e)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and sheet,city state.and ZIP code)
Does applicant wen property in any other If yes,what county? • I What Taring District? I Has this deduction been requested on property
muntyinIndiana? I —_ f� W?n_ _I�. .. _❑ No
❑ Yes ❑ No - �7�(//'y�
COUNTY AUDII Drawer NO....(/,1)„l,/, ,.•,•
Deduction approved in the amount of /'J( ///�
20 20 20 20 Card NO. 4LOL/ `� -
Signature of County Auditor Coto
I
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
comer I contract buyer of the aforementioned property on date application is filed.
Nile naive) Date(moth,day.year)ciztt
r FID 'pt.. ,pant number x1t,/�a'n: 4 iPfwk ,A)C GT° t r `7(]0
_ authorized by my tied Power of AtromeN or by 6- .1-12-0.7` Date(month,day.5�)
Address of authorized person (number and street,city///,state.and ZIP cede) .