HomeMy WebLinkAboutMortgage_Adkins .a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
bi., ' FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R11/6-09)
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Prescribed by Department of Local Government Finance
INSTRUCTIONS: ` JA—..1 ii--../ '
Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought IN+YCAItr&,Ig8441
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months
before March 31 of each year the deduction is sought ❑ County Recorder
See reverse side for additional instructions and qualifications. PA4 {u
Applicant(owner ttract buyer-see -' nd on reverse ale) M /1 GIBS ON COUNTY AUDITOR
Taxing 0istrict Der{ / d 1 1 , Record number P e n
-aoo - tit-01 13 1, 4
Assessed valued real property as of Matgage Itracrt indebtedness unpaid as of Mortgage/Contract' debtedness unpaid as of Is the appfant the sole
March 1,asrara year 1,current }� date of apPfrcation legal o equtade owner
/ 5(// ❑ Yes ❑ No
If no,what is his/her exact share of interest? a 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
•
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller I�� .
Address of mortgagee or contract seller(number and street.city.state,and ZIP••••4
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP c
Does applicant own property in any other If yes, 7 ��,, ... deduction been requested on property
county in Indiana? ❑ Yes ❑ No Drawer NO... it year?
❑ Yes ❑ No
Card NO. ...LiCQ. 1.•••..
Deduction approved in the amount of: -
•
20 20 20 1 20 I 20 20 20
Signature of County Auditor - County Date(month,day,year)
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 I contract buyer of the aforementioned p/••-rty on date application is filed.
•. :(own, s• 'name) / // Date(month.day,year)
4.._ --_ .-// �dA
RA :_ • :. _.of applicant(number and scree city state,and ZIP code)
Person authorized by duly 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 ZIP code)