Mortgage_Fidler (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
' FOR DEDUCTION FROM ASSESSED VALUATION
44.:T : State Forth 43709(R11/609)
- Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS:
M be filed in person or by mail with the County Auditor or County Recorder of the county where the property is local
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought for
2)Mobile/Manufactured Homes not assessed as Real Property Must Re during the twelve(12)mon s
before March 31 of each year the deduction is sought - ID County County Recorder
See reverse side for additional instructions and qualifications. M n 28 2014
App6pnt(ownerd for contract buyer-see restrictions on reverse side) _ • 2-,e) ■ . 73 CP• / V a r • / �,
is4u7 Key number/legal description -..•117.i•r:!anfI P;i.e number
T y� a& ' IA - /5- 30q-00a . a 0 a -Q�BGIB$ONCOUNTY •UDITOR
• -•value teal property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Mardi 1,ascent year March 1,axrrent Naar date of appfiat in legal or equitable owner?
q 00p ❑ Yes El No
If no,what is his/her exact share of interest? J If owned with someone other than spouse,indicate with whom
If name on record is different than that of apt.indicate below: Is the property in question Annually Assessed
❑Real Property ❑Nmually Assessed
- Mobile Hone QC 0-1.1-7)
Name of mortgagee or contract seller -
Address of rtorgageewmnhacd seller(number and steel,dry,state,and LP code) Drawer NO ,, //()1/g
•Name of assignee or other owner or holder of mortgage Card NO. . • .Zi —
Address•/r ee(number and street cry,stare, IP code �WWrr���
• . , . 70 3//O Yha S
Does applicant own property in any.0 er . If yes,what county? • What Taxing District? Has this deduction been requested on property
mainly in Indiana? for current year?
❑ No
❑ Yes ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount oft
20 20 20 20 20 20 20
Signature of County Auditor County Date(rtorW,day,year)
4.-A-,....4../L4—
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�proopee/rt on date application is filed.
\.c - thm ) . 4,44_6.4_ Date(month,day,year)
Full resident address of want(number and sheet, ,- ,state,and7J code) '
4,7 40 I0 d 4 . %firms / , La7L, 4t 76 70
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,city,state.and LP code) .