HomeMy WebLinkAboutMortgage_Hollingsworth ••'^n STATEMENT OF MORTGAGE OR CONTRACT INDEB of Township Year
- -N. ' FOR DEDUCTION FROM ASSESSED VALUATION Iii p r
'-"f"` . State Form 43709(R12/6-14)
it ,a„ E Prescribed by Department of Local Government Finance
INSTRUCTIONS: OCT 19 2015 File Mark
To be filed in person or by mail. Form filed with:
Firing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the ctio • f� t}c�� County Auditor
Must be Wed or postmarked with the County Auditor or County Recorder Q the perry is J'7 tY
located on or before January 5 of the immediately succeeding calendar94 ON COUNTY AUDITOR ❑ 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 sought. •
See reverse side for additional instructions and qualifications.
Applicant(o r7 a contract buyer-see restrictions on revers s' e)
Dist t1/t Key number/legal description Record number Page number
a AZOO 26-/Q-4,- 2CO cc 02370a 7 /5-4,4 I I
Assessed value of real propertyps of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Mardi 1,current year March 1,current year date of application legal or equitable owner?
. —7/ 000 ❑ 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
El Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or con t seller
T U _-
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
140LL CDG.SLA.,olcrke A
Address of assignee(number and street,city,state,and ZIP code) C.I-L Y L
a/A LLc vrak-
Does applicant own property in any If yes,what county? Wha 7/ `� T µN2 ies,state amount of deduction
other county ❑Yes W G
in Indiana? ❑No / 1J_ 7 I/
A person is not entitled to this deduction unless the person has a Ol that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recoraer s urwcr 0,—........______ . Se deduction.
COUNTY AUDITOR .
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County I Date(month,day,year)
11 We certify under the penalty of perjury that the above and 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.
Signatur§,(o nets full name) Date(month,day,year)
,c‘ l tg1-(:far y> � • 10-/9- 0
Full resident add ofapplicant(n ndstreyet�city state, d IP code)
227 �', lot /Id' Ac rpm etem /AI '�/7l� 7D
Person authorized ed by duly executed Powe 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.