HomeMy WebLinkAboutMortgage_Blackburn 0 r.,. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
Aft, FOR DEDUCTION FROM ASSESSED VALUATION
Voril State Form 43709(R12/6-14)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. �� {,Fo m filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. /JC.�
Must be tiled or postmarked with the County Auditor or County RecordeMAfpe ootnty{wpere the property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar yea/. l" U CU 15 ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file y(ith the County Auditor of the county
where the property is located during the twelve(12)months before Ma of.eac year he deduction is sought.
See reverse side for additional instructions and qualifications. J�'1Pik
GIeSp
Ap lip cant(pwcer o ct er-s rte[/, ^J}r OR Record num Page number
. 26- 9-/8'-. / - 0. 4d/-0 E io ao7
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,anent year March/1,�current year date of application legal or equitable owner?
te/ht 3a 0 ❑ 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
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgaye4 or cJact set er _ r-� XM i
- —
Address of mortgagee or contract seller(number (nd\\`streeet,city,stale, d ZIP code)
^�t rX�
Name of assignee or other owner or holder of mart 'a o l S— cfl V
s�4 E• �C�b,�rr
Address of assignee(number and street,city,state D 1 11 N'C C I 0 \ tjil `
Does applicant own property in any If yes,what, ( been requested If yes,state amount of deduction
other county Card N0. .... 1•�
in Indiana? ❑Yes ❑No 7 Yes ❑No _
A person is not entitled to this deduction unlee . ,..-__....__ �„„rc persun 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 20 20 20 20
Signature of County Auditor County Date(month,day,year)
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.
Signature efs full name) Date(month,day,year)
Le
r' Full resident 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)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed S10,000.