HomeMy WebLinkAboutMortgage_Dyer flSTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION State Form 43709(R12/6-14)
Prescribed by Department of Local Government Finance FILED D
INSTRUCTIONS: 11 ���JJJ
To be filed in person or by mail. En ,(i with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. JUN 172U15
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is LJ County Auditor
located on or before January 5 of the immediately succeeding calendar year. . -r. •- -ecorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the co A , --G� 1t1��
where the property is located during the twelve(12)months before March 31 of each year the dedugottis •Z���.
See reverse or additional instructions and qualifications. / OUNTY AUDITOR
Applicant(o contract buyer-see . 'cuon/.n reverse s' / 1 /
T.; a nu ber/legal descri• I Record number Page numb:
' Y 9 a 9
Egg--. . i,T sa- O . S.7
Agea sed value of real p•pe as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtednes- npaid as of Is the applicant the sole
Mardi 1.current year March 1,current year date of�opli1 ac) legal or equitable owner?
TNI,// ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than pouse,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 or contract seller
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Address of mortgagee or contract seller(number and street,city,state,and 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.who ///��� fuction been requested If yes,state amount of deduction
in Ind county ❑No /L. / 'lryj� 1 for other ❑Yes �(-/J✓", (.tom,-7u,/,t/')'_ ❑YBS ❑No
A person is not entitled to this deduction unit or contract indebtedness that is recorded in the county
recorder's office(including any home equity rice)that is the basis for the deduction.
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Deduction approved in the amount of: /
20 20 15-6
20 20
Signature of County Auditor . 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
owner/contract buyer of the aforementioned property on date application is filed.
Sgnature • ers full name Date(month,day,year)
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Full resident address of applicant(number and street,city,state,and ZIP code)
1( / 795 n/ 35n r oici,wca4a S/ I 217 6 70
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 510,000.