HomeMy WebLinkAboutMortgage_Bane (4) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
2 �;
��—�� Plats Prescribed 43709 Department(R12/ ent) FILED
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be fled in person or by mail. Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the degfrOprgistlogt
Must be filed or postmarked with the County Auditor or County Recorder of the co cotflcryqvirbrecthe property is County Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the Co Apdit; .,4j- county
where the property is located during the twelve(12)months before March 31 of eac f i, ,r iyf,7; is rasing.
See reverse side for additional instructions and qualifications. I INTY AUDIT
Applicant(owner or (buyer-see resvicrion�on reverse sib V 1890N co
7 isirict, Key number//)legal description Record number Page number
G d 6-0.5 c 57-/0o are c07 0/7 a o,�r /41
Assessed value of r property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Mardi 1,current y March 1,current year date of application legal or equitable owner?
/00 00 d ❑ yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate helow: Is the property in question:Annually Assessed
. ❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgag9e or contract seller
Address of mortgage r cot seller(number and street,city,state,and ZIP code) _ _�
Name of assignee or other owner or holder of mortgage 370/47
Address of assignee(number and street,city,state,and ZIP code) U r $T C r N O••• •
y/1
Does applicant own property in any If yes,what county? -What Taxing District? Card NO. ` r (/[. ••• uction
other county
in Indiana? ❑Yes ❑No ,
A person is not entitled to this deduction unless the person has a balance on the person roc rs recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county reuuroer s office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 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
own- .. act buy .ef ths-aforementioned property on date application is filed.
Signal -(owns - Date(month,day,year)
1C AS ��alcP� 9-/3- !S
Full esident adry e ss o n ( mber and street,city tale,an de)
3587Gr1c 8Ccs>
7/a sly .ril/ l7d 6
Person authorized by duly executed Power of Attorney or by 1e4-1.1-12-0.7 Date(month,day,year)
{X13- is
Address of authorized person (number and street,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.