HomeMy WebLinkAboutMortgage_Cox (2) t‘.a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County I Township I Year
it_ '" FOR DEDUCTION FROM ASSESSED VALUATION
•' State Form 43709(R12/614) FILEb
� Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be riled in person or by mail. JAN 7 eed 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 property• ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. I r, • 0 ai ounty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the c•. f vgfin
where the property is located during the twelve(12)months before March 31 of each year the de 1B.SONo n,g, N • • e s OR
See reve e side for additional instructions an ualifications. -/�//�/
Applica w er or tract buyer-se tic' n reverse
number Page number
oiea '-% 7 Q/- J 066. del- 4c/ 1s
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?
/ r/ ?3cC 3 ❑ 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
),yam Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller lig �� / r"" —
((er /
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) �Q�o�2�.�
Does applicant own property in any If yes,what county? What Taxing District? Has this uction be n requested I If yes,state amount of deduction
other county on property for
in Indiana? Yes ❑No current year?
❑ ❑Yes Li 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.
Deduction approved in the amount of: Ca? L `_c_1ll I -1
SID y/ BeAN Oft fit
20 20 20 20 20
/5-3W
Signature of County Auditor ' Date(month,day,year)
•
I/We certify under the penalty of penury tnat the aoove artu,tit eyun,y ode and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signature(owner's full name) Date(month,day,year)
Full resident address of applicant(number and street,city,state,and ZIP code)
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1 ' Person authorized by duty 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.