HomeMy WebLinkAboutMortgage_Shoultz (4) .,• STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count Year
. w ' FOR DEDUCTION FROM ASSESSED VALUATION y Township
State Form 43709(R12/6-14)
Prescribed by Department of Local Government Finance IL
INSTRUCTIONS:
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To be filed in person or by mail. - �a..F�orm filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is soMe R ? c
Must be filed or postmarked with the County Auditor or County Recorder of the county where the pro rtj5 t U�J 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 County Audi Q•f the co.my
where the property is located during the twelve(12)months before March 31 of each y�rrhe ..:1',•...•j.;gri.+f.
See reverse side for additional instructions and qualifications.
3ON COUNTY q(jDtTOK
Applicant(.tr or contract buyer-see restnctio rc rev; :s•e)
11 . .. 1 1 ui _ atL
m Di c , • u ber/legal description Record number Page number
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year Ma�1•cuirept year date of application legal or equitable owner?
-�j/[//) ❑ 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 below: Is the property in question:Annually Assessed
�2eal Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortga r contract seller
Address of mortgagee or contract and street,city,state,and ZIP code)
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 ' If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes ❑No current year? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balanc, Q S� 1 recorded in the county
recorder's office(including any home equity line of credit that is recorder `)>✓v e�"y �• �L uction.
CC to G A C t
Deduction approved in the amount of: NO
`-�S- l
Drawer
aolc3 - 1L31
20 20 20 Card NO. ''�( 1`lotooa 20
Signature of County Auditor day,year)
I 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/contract buyer of the afore jutioned property on date application is filed.
Rgature(own/ id,:me) Date(month,day,year)
/yam r 7`l ,(/�
Full residddress of applican (number and sire t,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)
The penalties for perjury can include imprisonment up to two and a haff years and a fine not to exceed 510,000.