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HomeMy WebLinkAboutMortgage_Bates za°4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year ea,_,_ ? FOR DEDUCTION FROM ASSESSED VALUATION 3 • State fo rm 43709(R12/6-14) T Gi oq Ft.Branch 2016 Prescribed by Department of Local Government Finance 1 �q-�` INSTRUCTIONS: File Mark To be filed in person or by mail. n Form filed with: Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deductierf i9 sc4rat2015 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. ❑ County Recorder 2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the Cou I T. • where the property is located during the twelve(12)months before March 31 oft rhh,vvee 1117 i-pr y?•sought. See reverse side for additional instructions and qua lifications. 'Iy°U- OUNTY AUDITOR Applicant(owner or contract buyer-see restrictions on reverse side) John M. Bates Taxing District Key number/legal description Record number number Ft. Branch 26-19-18-302-000.255-026 ,\./ a08 - (I RS Assessed value of real props as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebt ness unpaid as of Is the applicant the sole March 1,current year March 1,current year date of application legal or equitable owner? 126,300 / 142,393 0 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: Is the property in question:Annually Assessed Fifth Third Mortgage Company O Real Property ❑ AnnualloAm Assessed .1-7) Name of mortgagee or contract seller 5501 Kinsley Dr. Cincinnati, OH 45227 Address of mortgagee or contract seller(number 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) Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction other cdunty on property for in Indiana? ❑Yes ❑No current year? ❑Yes ❑No A person is not entitled to this deduction 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 of: 20 20 20 20 20 20 20 Signature... • my Auditor ' / / Cou.Ifk Date(month,day,year) A/LLIA.. id.4/.//L`/ a A sLei We certify under the penalty of perjury that the above -nd 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. ignature >r••' " Date(month,day,year) F silent address of applicant(number and street,city,state,and ZIP code) 701 E Sinclair St. Ft. Branch, IN 47648 Person authorized by duty executed Power of Attomey or by IC 8.1.1-12-0.7 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.