HomeMy WebLinkAboutMortgage_Burkett STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
of
�;. FOR DEDUCTION FROM ASSESSED VALUATION
.:' State Form 43709(R11/6-09)
Piesoibed by Department of Local Government Finance F' 11E,
INSTRUCTIONS: ���..//// r'I
r
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. �Foco with:
Fling Dates: 1) Real Property:Must file during the year for which the deduction is sought .N-1 N®0 8015 Auditor
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.
Appfcant wnerormnoad buyer-see/ o re nN xes V /
GIBBON COUNTY AUDITOR
T Lahti Key number/legal desorption Record number Page numbbee
Laoti✓ c2 — 3 -Dl- Ave; - 0oA , o9s -oay 20/3- 8.5
ed
value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
Marts 1,cram year March I.current year date of applcatn legal or equeable owner?
173 0Cc) ❑ Yes El No
If no,what is his/her exact share of interest? If awned with someone other
If name on record is ddfaalt than that of applicant,Indicate below:
Drawer Nn.
Name of mortgagee or contract seller ' I /71.4 .15.er • ........ '
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) - Card NO.
............
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any other If yes,what county? • What Taring District? Has Nis deduction been requested an property
county in Indiana? for current year?❑ No ❑ Yes ❑ NO
❑
COUNTY AUDITOR
Deduction approved in the amount of: -
20 20 20 20 _ 20 20 20
Signature of unty Auditor 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 fled. .
nature(owner's full name) Date(month,day,year)
nature
,c?‘wau t,cR r
W resident address o(appikarit(number and sliest,cry,state,andLP code)
I�p7a s. ) ex. C c1Q-e-- P - midi TN q 7434
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(moron,day,year)
Address of authorized person (number and street,dry:state,and ZIP code)