HomeMy WebLinkAboutMortgage_Keller (4) a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
f.._.`.
��;: FOR DEDUCTION FROM ASSESSED VALUATION
State Form 93709 Department/6-09) �,�
Prescribed by Departmem of Local Government Finance // i - k
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor or County Recorder of the county where the property is berated. NO c F t[
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months
before March 31 of each year the d--. • n sought - n,1pp� ecorder
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See reverse side for additional instructions mil q,- i.ti.
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GIBSON C(111NTV AIIDITOR
Apprxanl or buyer-see - ".e
�S .v�7t4, S oS2a can
Taxing D� Key number/legal description Record number Page number
a �-ia -ill �U / 00 0 a 79 °RR � � �!9'Jo1
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the applcant the sole
Mash 1,arrant year t, t year date of apps abort legal or equitable owner?
l3 OoZ ❑ Yes ❑ No
If no what Is his/her exact share of interest? If 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 ❑MnrallyAssessed
• Mobile Horne(lC 6-1.1-7)
Name of mortgagee ar con con seller
�_Jl/may ,/r
Address of mortgagee or n er(numbd and street,ctly state,and ZIP code) /�/� �/
Name of assignee or other owner or holder of mortgage Drawer NO..../Yf 1!•1•......
Address of assignee(number and sleet,dty,slate,and ZIP code ti 9 7 {�
Card NO qC/
Does
applicant toown property in any other If yes,wt 4 r 0,o a9. requested on property
county in ❑ Yes 0 No ❑ Yes ❑ No
3 (L.
Deduction approved in the amount of
20_ 20 20 20 20 20 20
Signature of County Auditor t County Date(nand,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
Amer I contrail buyer of the aforementioned property on date application is filed. .
Signatum re nor ) r� Date(month,day,year)
(/����Lur� !(!/Gf20t�f
Full nl dress of fuant(n rand street.crN.state,and LP code) /
authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of autixxaed person (number and sheet dly state,and ZIP code)