HomeMy WebLinkAboutMortgage_Thompson .n+4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�` FOR DEDUCTION FROM ASSESSED VALUATION County Township Year
- t-, State Form 43709(R12/6-14) ".f" 1 1
%. ,m. .o•' Prescribed by Department of Local Government Finance �!-` ,1 ?; !. .
INSTRUCTIONS: File Mark
To be filed in person or by mail. n(`7 r Form fled with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the 6'rsddctibn is gt/gt 11.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is County Auditor
located on or before January 5 of the immediately succeeding calendar year .i County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with th:4,.;IA,-ay 179At the county
where the property is located during the twelve(12)months before Marc6Mgf1 aril erlo5kettypiittRught.
See reverse side for additional instructions and qualifications.
Applicant.own tact b se ons on reverse� Q.( Q (i 1 f)4 R aO'.-
g 4JSth Key numb / •f descn lion Re d number Page be
a it a 5 14-a5-k- oo-ocasci3-oa0 t)- f
Assessed value of real properly as of Mortgage/Con ct indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,curie ri cQ C O O� date of application legal or equitable owner?
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 properly in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contact seller 5�3
Address of mortgagee or contract seller(number and street,ci state,and ZIP code)
1
��1 :111'C Y j>\'O,.••• hat Taxing District? Has this deduction been requested If yes,state amount of deduction
.••. 12-
..... on property for
! current year? ❑Yes ❑No
Card j\O. /, a balance on the person's mortgage or contract indebtedness that is recorded in the county
•••. ....[.. 2 recorded in the county recorder's office)that is the basis for the deduction.
�- — _ 1 COUNTY AUDITOR .
Deduction approved in the amount of:
20 20 20 20 20 20 20
r
Signature o u ty Auditor County Date(month,day,year)
II e certify under the penalty of perjury that the above anc 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.
ignature(owner'sJ.�ufl nam ) Date(month,day,year)
PCo--Lc 6.4.—..,,T 2-a -
11 resident address of applicant(number and street,city,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.