HomeMy WebLinkAboutMortgage_Quinlin sSTATEMENT OF MORTGAGE OR CONTRACT INDEBTED
Cou ownship Year
FOR DEDUCTION FROM ASSESSED VALUATION J
State Form 43709(R12/6-14) -
Prescribed by Department of Local Government Finance 1 201
INSTRUCTIONS: jU` File Mark
To be filed in person or by mail. ' 4 I al Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is •. •. rrtjn
Must be filed or postmarked with the County Auditor or County Recorder of the county whe = '" f� -,-: ' AUDIT County Auditor
located on or before January 5 of the immediately succeeding calendar year. C• SSON • ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the CountyAuditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought.
See reverse side for additional instructions and qualifications. .
AppG own: or confect buyer. a restrictions on reverse side) ` •
T--'ng va oKey number/legal d cription Record number Page number
(9‘,—//9 /7-/e/ 600 607 D er ao/ 5 asap
Assessed value of real property as of Mortgage/Contract indebtedn unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,anent year Majg ,wn�l year date of application legal or equitable owner?
• Mt" 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 or coyyact sell -
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) _ -
Name of assignee or other owner or holder of mortgage �C' Z 0
�ot5 —
Address of assignee(number and street city:state,and ZIP code) FE �l\ 'N_R 1 'S 0
t _
Does applicant own property in any If yes,what county? What Taxing District? — _p\— \ Q J 'of deduction
bi other county (� ��-�
in Indiana? ❑Yes ❑No Q Ss)
A person is not entitled to this deduction unless the person has a balance on the pets 6C ueotedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the count; -,,,,,tie)that is the basis for the deduction.
COUNTY AUDITOR .
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of CountyAuditor 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.
Signatur-(owner' full name) Date(month,day,year)
/i 1=.� .,, 7- RO-15
WI resident ad•ress of applicant rte r street,city •.te •ZIP code)
K W/ S et4nk 4 7d
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. .