HomeMy WebLinkAboutMortgage_Dewig (11) STATEMENT OF MORTGAGE OR CONTR) CTUNDEBTDN County Township Year
ar' cn FOR DEDUCTION FROM ASSESSED VAIIATI6N f.
"`C ..14 State Fonn 43709(R11/6-09)
Prescribed by Department of Lod Government Finance
INSTRUCTIONS: M ° 6 2014 File Mark
Form fled wqo
To be filed in person or by mail with the County Auditor or County Recorder of : county where r e pro.-rty is located. fLLJed
Filing Dates: 1) Real Property:Must file during the year for which the dedu ' . •I County
2) Mobile/Manufactured Homes not assessed as Real Po�o e 'ti •'crei Npt,a twelve(12)months Court Auditor
before March 31 of each year the deduction's sougQ.IBS•N COUNTY AUDITOR ❑ County Recorder
See reverse side for additional instructions and qualifications. -
App6Unt(• or conoactb ..'.... Dore -ysde / /
A . :! is■ ■-.L: I .LL'-,. fiLA Imo,
Taxi i R - Key number/LT:.description 0 r Record Page number
! OQ0.. z- - 3 -06 - 30/-aoo, os14-009 Do? / 757
Assessed value real property as of Mortgage/CO indebtedness unpaid of Mortgage I Contract indebtedness unpaid as of Is the appOcont the sole
Marsh 1,artem year Marts 1,a date of epplxation legal ar equitable owner?
�� ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of app6rant indicate below Is the property in question:Annually Assessed
❑Real Properly El Annually Assessed
. Mobile home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and sheet ,s and code) 'K , 010,0 Q
Name of assignee or other owner or holder of mortgage
Ambulance Billing Services, Inc.
Address of assignee(number aM Street cam',state.and ZIP code) 911 Maryland Ave. • Elkhart, IN 46516 •
Yl� 1-877-293-3535 •www.ar ulancebill.us J �5
Does applicant own property in any other If yes,what c /, ✓ /�� �) �•, wt'
courtly in Indiana? ❑ Yes ❑ No F• �/ (�`'(O'( /;� J No
Of _$'0. &11.gr.
Deduction approved b the amount of.
LE
20 20 20 t:-.) W 1 _
ig Sg .. -of .,ry •itor
- i 9 P v
We certify under the penalty of perjury that the above: \O a na and
......., . _a—at...._., . fr' 7 owner I contract buyer of the aforementioned property or _`l7
'.nature.ii.,-es ,name
• .._J_4'. _e—Ala / 1
,.resid-�•. - of applicant(number idly state,and P code)
f /Sim.//re [�,c i�r Aa s ue/ ,��v x(03 9
authorized by duly executed of Attorney or by I 6- .1-12-0.7 Date(month,day,)ear)
Address of authorized person (number and street city,stare,and ZIP code) .