HomeMy WebLinkAboutMortgage_Novotny (2) `°•°o STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County I Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R12/6-t4)
W. Prescribed by Department of Local Government Finance
2016
INSTRUCTIONS: 8 2016 File Mark
To be filed in person or by mail. MAR 8 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 co my where the rope is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. ll[ • ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with th the county
where the property is located during the twelve(12)months before Marc,J{BSONfeekiD$'tedl tfp4TOSJght.
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions
Taxing District Kel1number/legal description - Record number Page number
chnsor\ Zlo -Ig35-IOC -OOQ. 179 -da li Rol 5- 55a.3
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 �1,� date of application legal or equitable owner?
(p.3 ( CO ❑ 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
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee pr contract seller
53
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) t I!/1` J/.� 3f (sc
Does applicant own property in any If yes,what county? What Taxing District? Has this deduc seduction
other county on property for r ''')
in Indiana? ❑Yes ❑No current year? OI D ^. SSoC
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or !the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's offic .
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 1 20 20 20 20 20 —
Signature of County Auditor I Couny Date(month,day,year)
I/We certify glider the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
o to act buye of the aforementioned property on date application is filed.
Signat (o j�full na� Date(month,day,year)
ull reside ddress f ap licant(number and reef,city,state.ar d ZIP ode 41(0311
go o � g. T64 Caw M1 S�c �� 11 11/
Person authonzed by duly executed Po r of Attomey 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.