HomeMy WebLinkAboutMortgage_Simpson (2) dig rx. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County I Township Year
. FOR DEDUCTION FROM ASSESSED VALUATION FILED
i,. ' State Form 43709(R12/Fi4)
-,,, : Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. Fred Iit2 2014
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year r r i c;"
2) Mobile/Manufactured Homes not assessed as Real Property Must file with the County Auditor of the county grt�1l
where the property is located during the twelve(1 2)months before March 31 of each year the deduction is sou
ggg$ N COUNTY
See reverse side for additional instructions and qualifications. AUDITOR
Applicant( wner or con buyer-seg'tilt.on'eyeless side)
Taxing ^4 Key number/legal descnp' n S er R m y P ge Vrl rCtt , 2& - -0 ut-LI o3-cc3. 143. oayf Wiibcurs
Assessed value of r e a l property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness u ' as of Is the applicant the sole
March 1,current y�� March 1.current year date of applicalian A legal or equittble owner?
// ) SY h le--Yes ❑ No
If no,what is lu4/her exact share of interest? If owned with sortie other than spouse.indicate with whom
If name on record is different than that of applicant indicate below. Is Up-property in question:Annually Assessed
Real Property ❑ Annually Asir-Pissed
Mobile Home(IC 6-1.1-7)
Nam+ of inertgagp
onto tract seller
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Address U mortgagee or c ct seller(number ands el,cRry.state and ZIP e) ���v
II r, eX rel-/n p$nd Zl it(' Wi II is 5 r) Al I `f
Name of assignee or r owner or folder of mortgage
Address of assignee(number and street any,state,and ZIP code)
Does applicant own property in of If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county �,/ I on property for
in Indiana? Yes Ya No current year? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
. COUNTY AUDITOR
Deduction approved in the amount of: - - -
20 20 _ 20 I 20 20 20 20
Signature of County 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 filed.
g ownar's ame Date(month, ay,year)
'c a��l �► n I i014?O'¢
-- Full resident address applica (n ben and street.c- sate,aM code)
8 5 . &-i bSm-) Prin c� Tt1 �f 7�7c —
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 sweet.city,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 510,000.