HomeMy WebLinkAboutMortgage_McClellan (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Township Year
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� = FOR DEDUCTION FROM ASSESSED VALUATION
' _lz State Form 43709(R1216-14) DULY ENTERE� Z�� r tra
—.—. Prescribed by Department of Local Government Finance (t0(,final ac �r as ¢f J .
INSTRUCTIONS:
Subiec day of --� File Mark
Filing be Dates:s:person Real l ro by mail. ��.h. Runt Form filed with:
udit
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for wh'ch the deducti I' sought. . .Counl
Must be filed or postmarked with the County Auditor or County Record the th- . :: y County Auditor
located on or before January 5 of the immediately succeeding calend 4�.j;!17I1: ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the Coun. _. •Jsr•- -•�-••. n
where the property is located during the twelve(12)months before Marr1I1actef i- • �I .cr� � �u.ht:U
See reverse side for additional instructions and qualifications.
Applicant(o contra uyer-see b s✓iQirnspn re a side)
T. . g C •'e• Key numberrr//legal description Record number Page number
A. a 6-ia -07-3dvcFl3. /4K oa 8 ao/5 ( 37/"
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Mardi 1,current year March vent year date of application legal or equitable owner?
. yo f941 ❑ 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: II Is the property in question:Annually Assessed
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mprtgoag�ee�or 7.--_ .5 t seller
Address of moyrt�agee or ontraccttt seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
1
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_1"' cunt of deduction
other county , property for _
in Indiana? Yes ❑No current year?- — •'
A person is not entitled to this deduction unless the person has a balance on the person'- red in the county
recorder's office(including any home equity line of credit that is recorded in.th"- rCOL PO )y ••..••
Deduction approved in the amount of: I' 1
20 20 20 20_ v - ,.•••• 20
,O, ..
Signature of County Auditor Cal. 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 I contract buyer of the aforementioned property on date application is filed.
Signature(Owner W name) Date(month,day,year)
Fun 7.-sOider nt address of applicant( umber and sti t,M,state,and Z17PL ode)
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$10,000.