HomeMy WebLinkAboutMortgage_Akers (5) .^.n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
County Township I Year
br : FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R12/6-14)
`�� Prescribed by Department of Local Government Finance Fi
INSTRUCTIONS: File Mark
To be filed in person or by mail. 0q .?015 Form tiled with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the ded 11kn t bug t.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the prop-rt . County Auditor
located on or before January 5 of the immediately succeeding calendar year. .i ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the Co it it t•-.1111777P) ourityno,
where the property is located during the twelve(12)months before March 31 of each y-- r d t:... .otktd®bayr
See reverse side for additional instructions and qualifications. GIBS°
Applicant(owner in tract buyer-tee W igia•on reverse
Tax" triyt, Key�//..er/legal description Record number Pa n b r
/c��yMV a is -o7 M ictO �?O as 7 ( S a
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 March 1,c rrent yearn/ date of application legal or equitable owner?
`j gCg a� ❑ 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
'R seal Property ❑ Annually Assessed
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Mobile Home(IC 6-1.1-7)
Name of mc�)ttg"ag"eeorr contract seller at
1
Address mortgagee or contract seller(number and street,city,Lsttate,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,stale,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 balance on the person'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 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.
Signature me? 1 J na e) Dave(month,day,year)
XII- si nt a ress of applic L2nd freer,city,state,and ZIP code)
Y3
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.