HomeMy WebLinkAboutMortgage_Queen o STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS count rwil ip Year
A I..• FOR DEDUCTION FROM ASSESSED VALUATION }1N{LJ �n6^J.
' it State Form 43709(R12/6-14)
�� � Prescribed by Department of Local Government Finance
INSTRUCTIONS: 1,F•ilegitarkz015
To be filed in person or by mail. J(J IV Form filed with:
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 r�4 :;i Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the CountyAuditor of th�'�N Co ' oA Offer
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought.
See reverse side for additional instructions and qualifications.
Appl' owner or contract buye ee restrictions on reverse side) 1
Vuetre. x�
T n Disy�t / Key number/legal description Record num Pagg:grit
2Fo,CaY ca', -f//-is- ion- 003. 972- o� 9 J �'l)
Assessed value of real property s of I Mortgage I Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year date of application .{Q Q o o legal or equitable owner?
/, 7 QO ❑ 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 O Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
GaiC/C6t J C7f2fl nS
Address of mortgagee or contract seller(number 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 count) ! D been requested If yes,state amount of deduction
other county -O.
in Indiana? ❑Yes 0 N D).a„e1 /'��� y,I/ 'Yes No
A person is not entitled to this deduction unless the may}' JC'( I ..,,,, tract indebtedness that is recorded in the county•recorder's office(including any home equity line oft
Card N O. j„! `f it is the basis for the deduction.
Deduction approved in the amount of:
20 20 20 I 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 r ntract buyer of the aforementioned property on date application is filed.
Signature /net /I n , Date(month,day,year)
/ a/r/acPc--
F dent a dress of a. t(number-nd stre city,state,an Z�code)
d3 9 v A y`Amcor/Ai , \.1242-- dit16
Person authorized by d ' -xecuted 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 S 10,000.