HomeMy WebLinkAboutMortgage_Ellis s STATEMENT OF MORTGAGE OR CON Tit t3 County Township Year
fS J
FOR DEDUCTION FROM ASSESSED VA
.:--t State Form 43709(R11/6-09) �''
Prescribed by Department of Local Government Furore
ws7RUC17oNS: DEC 2 , 2014 File Mark
Form fled with:
To be filed in person or by mad with the County Auditor or County Recorder of the county where the ty• is located.
Filing Dates: 1) Real Property Must file during the year for which the deduction is a •ht �! gt. County Auditor
2) Mobile/Manufactured Homes not assessed as Real P 'r^'A I a■ :.ii. nths
before March 31 of each Property:M1j;lo
year the deduction is sought G1BSON COU Al County Recorder
See reverse side for additional instructions and qualifications.
Appttanl own or buyer- on re side)
D Pl .�„ . 6
i .District
Key number/legal d�r,.4 Record number Page number
NT. .. czap .. -- - - - ,. .... -40 / 3e)
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the applicant the sole
Mardi 1:anent year March-31 s¢n 3
data of application 0 Yes ❑ oN
-If no,what is his I her exact share of interest? / �•f/ If awned with someone other than spouse,indicate with whom
If name on record is dlRerent than that of applicant indicate below. Is the property in question:Annually Assessed 25. eal Property ❑AnnuallyAssessed
Tom' Mobile Home(IC 6-1.1-7)
Name o ee or contact s. /
a••A;: . -/ i4
-
Address of morgag-1-. contract seller(number and sheet city,state,and ZIP code) " "
/ V
Name of assignee or other owner or holder of mortgage /.. \`r l}-� O
Address of assignee(number and sheet city,state,and ZIP code) E*. QE.g.,1 l.l'
al
✓
Dees apaanl own property in any other If yes,what county? • \ k\— _ _fled on property
county in Indiana?
❑ Yes ❑ No ❑ Yes ❑ No
COUNTY AL
Deduction approved In the amount of:
20_ 20 20_ 20 20 20 20
Signature of County Auditor • Courtly 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/contract bu r of the afumementioned property on date application is filed.
Ina, eo ) Date(month,day,year)
!' address of (number and street city,state,end ZIP code)
''tZ tX / 37 y vc l5eo , i,N 47(DLi 9
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 steet,city,state,and Z/P code) .