HomeMy WebLinkAboutMortgage_Staples imii at.2 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Court Township Year
a"'_n.4, FOR DEDUCTION FROM ASSESSED VALUATION S i
1-)1/2 FOR
State Form 43709(R12/6-14) 1 �-{/
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. JUL •1 •
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 a C. yAuditor
located on or before January 5 of the immediately succeeding calendar year. I -^. .i
2) Mobile/Manufactured Homes not assessed as Real Property Must file with the County Auditor of •• ` 'a.1/�p,my Recorder
where the property is located during the twelve(12)months before March 31 of each year the ded en ' -IN. _O L • ' • :
See rover e side for additional instructs ns and qualifications.
t owner or contract buyer-see re cnps on revers v )
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District I Key rIi ll al description R number Page number
wv -ry-09 �3c o1- lc/�ca>S ors - aoCa
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 Ma tt(/Y\ea( C ( l` date of application legal or equitable owner?
VU0 ' [�Yes ❑ No
If no,what is his/her exact share of interest? I If owned with someone other than spouse,indicate with whom \\
If name on record is different than that N applicant,indkale belwrr� tyre property in question:Annually Assessed
r r / � rUh•fJ
Real Property ❑ AnnualtyAssessed
III Mobile Home(IC 6-1.1-7)
Name or mortg ee mn seller
Address non ' or tract seller(number free[city,state, ZIP e
501 ���� � �� n 1 owe) i tv�(h )(9 ��1 �h� 5
Name of assign or other owner or holder of m age / )
Address of assignee(number and street city state,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 El 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 properly on date application is filed.
Sigma Oname) pate mo th,
( {r deY YFa)
Ful residet11 adtlress of applicant bepend t illy,slat? and
(9 CO. . ,7 . : io:nc L, Qr1 41(.9 q y
Person authorized by duly executed Power of Attorney)Or by IC 6-1.1-12-0.7 I Date(month,day,year)
Address of authorized person (number and street,city slate,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.