HomeMy WebLinkAboutMortgage_Lewis (19) ,.•^•moo STATEMENT OF MORTGAGE OR CONTRACT INDEBTED SS A, FA Township Year
_, ' FOR DEDUCTION FROM ASSESSED VALUATION 1
L State Form 43709(R12/6-14)
•\ ; Prescribed by Department of Local Government Finance C CQ,�
.0 INSTRUCTIONS: 1 J File Mark
To be filed in person or by mail. Ii Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the dedu '.n is ','T;11. R
Must be bled or postmarked with the County Auditor or County Recorder of the coun 'h iv--"741. optopt, 0 ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year ,��,f1�9004 ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with tt So$'Auditor of the county
where the property is located during the twelve(12)months before March 31 onrch year the deduction is sought.
See reverse side for additional instructions and qualifications.
Appl' nt(owner or contract buyer-see res coons on re a sr ) � � � �
T "ng Dis ct Key number/taiga descnptio Record number Page number
�— 26-/8-.36- -9O3-ooa1/4.3ao cog dots 132
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I 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?
!/` 5: -) ❑ 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 mortgagee o ptract seller
3
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 county? What Taxing District? F ""—>1 VAC_ Amount of deduction
other county c ' Q i s— .- #3< -
in Indiana? ❑Yes ❑No c
A person is not entitled to this deduction unless the person has a balance on the person's D 1 a 11 e I- N NO he county
recorder's office(including any home equity line of credit that is recorded in the county re( to— t S— IS
Zikr.tiCktn W, L.ewls- d
COUNTY AUDITOF Card NO. �_
Deduction approved in the amount of:
20 20 20 20 ��''1(O �O S�3 k. 0
LCS0c,J_ ,or]
I
•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. l
Signatur owner' full /� Date(month,day,year
Fu ide address of pp6cant(nu ber and street,city,state,and ZIP code)
arson 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) .
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The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 510,000.