HomeMy WebLinkAboutMortgage_Grounds t''•4 STATEMENT OF MORTGAGE OR CONTRACT INDEBT SS County Township Year
.. r! FOR DEDUCTION FROM ASSESSED VALUATION
.-,
..t State Form 43709(R12/6-14)
\-,-„,-,. Prescribed by Department of Local Government Finance
INSTRUCTIONS: - OCT 5 File Mark
To be filed in person or by mail. 2015 Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the d-:uction is sought. �/,
Must be filed or postmarked with the County Auditor or County Recorder of the .47• whe e the 1 ro•en is VA. County Auditor
located on or before January 5 of the immediately succeeding calendwagg ' Wring
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with tird t bilnt klAprti(orrq ((tI77 ,�county 111 County Recorder
where the property is located dudng the twelve(12)months before March 31 of each year the dedil6Mldifught.
See reverse side for additional instructions and qualifications.
Appti�ant(owner tract r-see restp.{ionsno�n tre�(v,,e)rrsJre!�side�^)'ry�' �• r}l`` i
I�p\g7��G Key number I legal description `!y`\y Record number Page number
‘111Cemc 2 —1 9 -19 - 103 005. 1 3a - a a b 1G 363
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?
O O0 ❑ Yes ❑ No
If no,what is his I 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 Assresed
9 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,cifv-stain.n,„4.71),code) /./V,
d = `�
Nam r Lv r-. tL C�fmU) le p^
Addn `o •
"-a V -J
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O O
Does: \V t l -->!! yJ ling District? Has this deduction been requested If yes,state amount of deduction
other ..1`-r\S— J`) on property for
inlndc \—an-- \S current year ❑yes El No
A pers -..._ rr unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in 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 oft
20 20 20 20 20 20 20
Signature�� my Auditor / County Date(month,day,year)
/0—OS—IS
I We certify under the penalty of perjury that '- a1 nd foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyJ a aforementioned property on date application is filed.
Signature 7s full \ Date(month,day,year)
D re (addr of applicant(nuJmbe78nd street,city,state,and ZIP code) /�`
90o- S G.i74'Cin S)i /�r7G-71 /^J, `-/761 T 11
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.