HomeMy WebLinkAboutMortgage_Jaquemai ISTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION State Form 43709(R12/6-14)Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
Filing be filed s:person Real by mail. ti s P Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which th d ti is so
Must be filed or postmarked with the County Auditor or County Recorder of th cou e f r • ounty Auditor
located on or before January 5 of the immediately succeeding calendar year. I 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 eadJAt t117 dedgifp is sought.
See reverse side for--.i[ional instructions and qualifications. • O,y,.
Applicant(owner r_see res'• eons on -Verse side)
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Taxi;([ist id ' Key num er/legal des tl/` COUNTY AU PFef(Q number Page number
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Assessed value of real property of Mortgage I Con' t indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,can lJ�l/ date o,application legal of equitable owner?
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171/
❑ Yes ❑ No
If no.what is his/her exact share of interest? ' If owned with someone other than spouse,indicate with whom I
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 or contract seller
I I i
Address of mortgagee or contract seller(number and street,city,star= •nd ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
1 What Taxing District? Has this deduction been requested If yes,state amount of deduction
-a01...1t\.1 N1' on property for
�,"2_%_.h WC- r\ current year? ❑Yes ❑No
)erson has a balance on the person's mortgage or contract indebtedness that is recorded in the county
-3°-'i u„e14\2\ j .e (o,,„S redit that is recorded in the county recorder's office)that is the basis for the deduction.
CRC,-`1■\'<.‘ t/ au GUS: COUNTY AUDITOR
.20th - J ).t{ 1
20 I 20 I 20 20 20 20 20
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Signature.f C-un Audit County Date(month,day,year)
/Wrtify under the penalty of perjury that thentfd 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.
'gnature(owner's full name) Date(month,day,year)
'rlir 'a res r ' ing et city
Full reside aLt a ress of applica (numb r n street,aty,Isate,and ZIP code)� (a5115 / 5-0E / ir/ ki /fJ tt 767d
Person authorized by duly executed Power of Attorney or by IC r 6-1.T-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 S10,000.