HomeMy WebLinkAboutMortgage_Harper :.,41,,I.9, STATEMENT OF MORTGAGE OR CONTRACT IN TEDNES Orgy Township Year
FOR DEDUCTION FROM ASSESSED VALUATIO 1
!''-7,,,
1-t State Form 43709(R11/6-09) A 9
prescribed by Department of Loral Government Finance
INSTRUCTIONS:
APR 14 2014 File Mark
lb be filed in person or mail with the County Auditor or County Recorder of the county where the Form mad with:
Pe by �' h ry property located.
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. .ounty Auditor
2)Mobile/Manufactured Homes not assessed as Real Property Must Re d l�r )months
before March31 of each year the deduction is sought. GIBBON COUNTY AUpT R 0 County Recorder
See reverse • e for additional instru�_cti1ionns�yand_q 7alifications.
ATppfrant( L ` 1$}I bu �%Iral +e tm ben P or
/�J����JI,/�`��''�rr^1 lye` -09—/n9—cm. 907 i�f ?3
value of real property, as of Mortgage/Con vvv�r1Cddebtedness unpaid as of Mortgage/Conaad indebtedness unpaid as of Is the applicant the sole
1,=ea year March 1,wr ty$d ^� date of epPrecation legal or equitable owner?
CY ❑ Yes ❑ No
If no,what is his/her exact share of interest? If waled with someone other than spouse,indicate with whom
If name on mod is different than that of applicant,indicate below: Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
I 1 I� ry py/q \/1 /[/.'��{. Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller Vl5 \\ILr�'l_.C/-rV�—I v I_t
Address of mortgagee or contrail se Y
Namedassignee or other owner or Ambulance Billing Services, Inc. *
•. S ' ' 911 Maryland Ave. • Elkhart, IN 46516 ress of assignee(number andsl rill 1-877-293-3535 •www.ambulancebill.us )'LI
Does applicant own property in any �,,, eduction been requested on property
county m Indiana? Q t yeah ❑ Yes❑ Yes ❑ No
Deduction approved in the amount o —C-
r-� T CA
2,0 20
— I v 1 :0 20
rb W Date(month,d�lYDey'I- r r
`w.-L 1 J / , V lA/1t-'l�Jt
it We certify under the penag iplirant is a resident of Indiana and
owner/contract buyer of the
Sig re( fug nano) �/'�`�C/��. Date(ny'/m�/Jy�,day year)
!F�n;� t(num/b/era7rd sbeet�al�y,state,and ZIP cop @e)� ,. ,( ` , 1 I '�'G10 I
Persion 'ai Ids •-['aCsa>mrnek3 by IC 6-1.1-12-0.7 le-VlY�l'�QV-T ( N �c��p 3 fmw,N,day,road
Address of authorized person (number and saeef,dry.state.and ZIP code)