HomeMy WebLinkAboutMortgage_Brock (2) .DER=t�, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS CountyTownship
� �� \� Year
:, ,: --,;*\;". FOR DEDUCTION FROM ASSESSED VALUA
x'\�- mot 1a State Form 43709(R14/1-20) Il2020
\�''`� --' Prescribed by Department of Local Governmen .Hanceleg
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INSTRUCTIONS: To be filed in person or by mail. 0 ile Mark e Form filed with:
Filing Date: Form must be completed and dated'n the ca IIVioar year for which the deduction is sought. RI County Auditor
Must be filed or postmarked with the unty udlior or County Reaordero the county where the property is
located on or before January 5 of the ca/en a year in e. ❑ County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restriction r verse side) w -\\fre,ii \.'"")
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Co � rv'11f\ `
' t Taxing Dist ey umber legal de ri lion Record number Page number
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the pplic nt the sole
assessment date,current year assessment date,current year date of app'cati legal o eq table owner?
U� Yes ❑No
If no,what is his/her exact share of interest? If owned with some a other than Spouse,indicate with whom
If name on record is different than that of applicant,indicate below: l t e property in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contracts I
ILE
fly________
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
0CT 212020
AddressDrawer . p 'C)
Does ap faxing District? Has this d-
on property . STY tN V
in Indian l ���� cu e®'�l k-4L3- :s5 0
A perso, C a t-(.l �T O. t dance on the person's mortgage or contract indebtedness that is recorded in the county
recorder ,rded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approvea in me amount of: `
20 0/ 20 20 20 20 20
Signature of County Auditor County \ Date(mont ,day,year
iiiikfr
I I We certify un.er th . perjury that the abo egoing information is true d correct and that the applicant is resident f Indiana and
ow /contract buye - e aforementioned property on date application is filed.
Sign
aLowne = ' I name) Daten day, ear)
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Full -sident address of applicant(number and street,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)