HomeMy WebLinkAboutMortgage_Kissel (3) inn* STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
-\- ,.
" 4 FOR DEDUCTION FROM ASSESSED VALUATION
:J, '! State Farm 43709(R12/6-14) •
S "1 Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS:
To Filing be filed in person Real or by mail. � C : r
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 9
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought. JUL 24 2015
See reverse ide for additional instructions and qualifications.
Applicant(o .- or contract buyer-see ms .•••ns on reverse sid-'
iltuictkit
1/S1_ . ru A: a . i _
Taxing Distri• K number/legal description Record . N C arbtHAU DITOR
- 1-c.A- 2o0 -000. 2w1- biz'? / 3a5I��(
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sate
Mardi 1,current year March 1,current year date of application application
legal or equitable owner?
53 r-IJ O S ❑ 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 contract seller /\ / '
Address of mortgagee or contract seller(number and street,ciryP cC��)
Name of assignee or other owner or holder of mortgage - ..
Address of assignee(number and street,city - °1 0 1. .. .,,,.,,
Drawer NO.•
Does applicant own property in any If yes,u [eduction been requested If yes,state amount of deduction
other county !�/�5 ryfor
in Indiana? ❑Yes ❑NO - -.-)L1... aR ❑Yes ❑No
- A person is not entitled to this deduction m
Card t O, n e or contract indebtedness that is recorded in the county
recorder's office(including any home equit �J,,�� Cp )ffce)that is the basis for the deduction.
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County Date(month,day,year)
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 af•rementioned property on date application is filed.
Si• -tu.-(o era i na -) : Date(month,day,year)
* ,/i2Z' /�
F re- - .d•ress of.41.1i nt(nt and street,city,state,and ZIP code)
Pe •n authorized by duly executed'aver 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.