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HomeMy WebLinkAboutMortgage_Fox 0 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year FOR DEDUCTION FROM ASSESSED VALUATION State Form 43709(R12/6-14) Prescribed by Department of Local Government Finance T �y[/g...��� INSTRUCTIONS: ° I M 'A To be filed in person or by mail. Form filed with: Filing Dates: 1) Real Properly: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 OCT 6❑ .�'qty 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 of the county where the property is located during the twelve(12)months before March 31 of each year the deduction is so See reverse side for additional instructions and qualifications. GIB SON C OI I N7Y^U Appli.i owner or contract buyer-see restrictions on reverse side) DIrOK 4`///sue Taxin.District / Key number/legal Record number Page number a6 - /9- a8 - /00 -ooa. 570 _ 0A Ao,5 3702 Assessed 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,current year March 1,current year date of application legal or equitable owner? la 0) O U Q ❑ 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: �� t ME � � 1 Name of mortgagee or contract seller ) v r 0, 3 Your Insurance and Risk Management Source Address of mortgagee or contract seller( tuber and street,city state,and ZIP code) Name of assignee or other owner or holder of mortgage • Address of assignee(number and street,city state,and ZIP code) Pr N43 2.8 3 /o I. ci 41;54 c —.- • r � Does applicant own property in any If yes,what county? What Taxing Distract? other county in Indiana? ❑Yes ❑No A recorder's person is office entitled to this deduction unless the person has is a balance on the person's re recorder's office(including any home equity line of credit that is recorded in the county re 5/3 COUNTY AUDITOI Deduction approved in the amount of: 20 20 20 20 Signature of County Auditor County 10 I/We certify under the penalty of perjury that the above a foregoing information is own contract buynCe_�ryi/of/t"he a> aforementioned property on date application is filed. 97$ ^_ow a v�ll J`l`? '''[,,,FFFUII resident a dr applicant(number and street,city,state,and ZIP code) I / �i G (��� (� .�L - �a � `I Risk Management&Insurance Specialists for Government Entities IS'', (o L rV 1{7th S�✓[Yx �7 T. r!, Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 1 info©BlissMcKnight.com . phone 309..661.1393 Address of authorized person (number and street,city,state,and ZIP code) 2801 E.Empire Street Bloomington,Illinois 61702-0157 The penalties for perjury can include imprisonment up to two and a half years and a fine nor ro exceeu J a yaw., . ---------------------