HomeMy WebLinkAboutMortgage_Beloat (2) :-;'Z -, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS I County I Township I Year
'°i _ t FOR DEDUCTION FROM ASSESSED VALUATION e�' .rr�pl
" .f State Form 43709(R12 16-14)
l: :j
\`� Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS:
To be filed in person or by mail. fill .Ie• t.: 115
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 County Auditor
located on or before January 5 of the immediately succeeding calendar year. / w �„
2) Mobile/Manufactured Homes not assessed as Real Property Must tile with the County Auditor of the courr�el}i�oc, ) �e mf1. r
where the property is located during the twelve(12)months before March 31 of each year the deduction is soL� . • • •UDITOR
See reverse side for additional instructions and qualifications.
ApI (owner esr "cns revers side)
1 e /04D CI410 �
Taxing District
Key number/legal description n j s� 3 -a-Ao I Record number Page number
Assessed value of real property as of I Mortgage/Contract indebtedness unpaid as of Mortgage/Contract incebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year date of application legal or equitable owner?
?e6ti�) 9 Yes 0 No
If no,what is his I her exact share of interest? If wined with someon 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
jpReal Property 0 Annually Assessed
pe Mobile Home(1C 6-1.1-7)
Name ofrt�ortgag or,wntrac,s/eJlgr /
Address of mortgagee or c ccol(.ntract/seller/r((nummber and street.city sat`tee,and ZIP code)
•
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,dry,state,and ZIP code)
Does applicant own property in any I If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
A, on property for
o
in ther Indiana? ❑Yes 1No current year? ❑Yes 0 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 recorders office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20_ I 20 I 20_ I 20 20_ 20 20
Signature of County Auditor I 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 I contract buyer of the aforementioned prop on date application is filed.
Signature(owners/u! me)
Data(mnity day,year)
Full reside t d ess of applicant(number and stree y,state,and ZIP c
S?6 t - 56 �� 7/tuiee i Ai 1/7670
Person authorized by duly executed Power of domey or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet.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 310,000.