HomeMy WebLinkAboutMortgage_Banet a? STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
-*a.p' State Farm 43709(R1116-09)
Prescribed by Department of Local Government Rnance
File Mark
INSTRUCTIONS: I
F• Q1- I ' I '
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 , County Auditor
2)Mobile/Manufactured Homes not assessed as Real Properly:Must file during the twelve(12)months .
before March 31 of each year the deduction is sought - �' rlf; li '• •er
GIB•e
See reverse side for additional instructions and qualifications. • . I i OR
- or contract-see on reverse side)
T . r/ c Key number/legal description Record Page number
;4 - Oen - 04, - a 00 - coo . 558-017 ?_o r 51 8 ,
Assessed vakre of as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the appfrant the sole
March 1 t trrent year March 1,current year date of apprmation legal or equitable owner?
3 0 no Q ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other Man 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 61.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract setter(number street,city,stata,and ZIP code)
Name of assignee or other owner or holder of mortgage
Add of assignee(number and sheet,city,state,and ZIP code)
Does applicant own property in any other If yes,what county? • What Taxing C T l-..' 4L••••h•'
county in Indiana?
Drawer 10• I
❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved In the amount of -
Card
20 20 20 20 20 20 20
Signa .or C-',/pry,"���`'N''-"/��,- County Date(month,day.year)
/,`
I 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 property on date application is filed. .
SignaWre ) 0 Date(month,day,year)
x � �-
I iesident address of applicant(numbers sheet,twit:state, nil ZIP code)
`7,2g5 ,r/. L Gs z� / IN 4764-0
•
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 sheet,dry,state,and ZIP code) .