HomeMy WebLinkAboutMortgage_Bailey (3) R3, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
FOR DEDUCTION FROM ASSESSED VALUATION
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. • i filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction i uxpt. !,lit
Must be filed or postmarked with the County Auditor or County Recorder of the county wh th R;✓i S" aunty Auditor
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 q(Ne,rglty'n i 5
where the property is located during the twelve(12)months before March 31 of each year the dedrz 22iibb ~girt
See reverse side for additional instructions and qualifications.
Appli t(owner or coptract buyer- ee restrictions on reve :side •
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T District - / Key number/legal descriptio -ecord number Page number
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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,anent year March 1,current year date of application legal or equitable owner?
. 6 gesDa ❑ Yes ID 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
Weal Property ❑ AnnualyAcsPssed
_ Mobile Home(IC 6-1.1-7)
Name of monger or naact seliar t� `
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) l\J,`�1�-
�i (`, eke \
Name of assignee or other owner or holder of mortgage p, ( TV ( I /
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Address of assignee(number and street,city,state,and ZIP code) C
a0 (S 3 �, I (, (
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction bee,,. 3/O S action
other county on property for
in Indiana? El Yes ❑No current year? ❑Yes ❑No 1
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is re.,__ 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.
Signatur owners full ) / Date(month,day,year)•
fir^ ^
// -/J. /J/J Z •
P Full resident zddre«o ppGrant(nudfie and street,c state,and ZIP code)
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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.