HomeMy WebLinkAboutMortgage_Jackson C•sm4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
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s • State Form 43709(R12/614) 2015
'i eu � Prescribed by Department of Local Government Finance
INSTRUCTIONS: F ILFM
To be filled in person or by mail Form filed with:
Filing Dates: 1)Real Property: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 OCT 2 002nls County Auditor
property is 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 f1/ :f--�
deduction is sought. � :;. 4''
See reverse side for additional instructions and qualifications. •> , • "'NTY AUL - :IA
Applicant(owner or contract buyer-see restrictions on reverse side)
Shannon H.Jackson
Taxing District Key number/legal description 26-18-36-400-000.690-009/908 W Elm St., Record num Page number
/Haubstadt, Indiana 47639 f11 G
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?
5128,960.00 jB•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
` teal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller —
Mortgage Masters of Indiana, Inc.
Address of mortgagee or contract seller(number and r g0 15-
501 N. Cross Pointe Blvd., Evansville, IN 47. Dra1y'CI' \0 v
Name of assignee or other owner or holder of mortgal ••
Address of assignee(number and street,c i t y,state,at Card \O' 11 v
Does applicant own property in any If yes,who..,.._...,: VIrlIell i axing uismct? Has this deduction been requested If yes,state amount of
other county on property for deduction
in Indiana? ❑ Yes O current year? ❑ Yes ❑ No
A person is not entitled to th 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 linen/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 of County Auditor County Date(month,day,year)
� �I/We pena t perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I ntract buyer of the aforementioned property on date application is ci5na ure curie/s lull name) ,/colt Date(month,day,year)
Full resident address of applicant(nu er and street,city,state,and ZIP code)
908 W Elm St., Haubstadt, IN 47639
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.