HomeMy WebLinkAboutMortgage_Roach (2) e'°•�v STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coon Township Year
°� F FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R12/6-14)
•°` '
, — ' Prescribed by Department of Local Government Finance I �
INSTRUCTIONS: l I :!'
To be filed 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. 1 5 m'a
Must be filed or postmarked with the County Auditor or County Recorder of the county where the properniB 1 r fIB: County 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 c• my I
where the property is located during the twelve(12)months before March 31 of each year the deductio j;• ./._�� i
See reverse side for additional instructions and qualifications.
/'� CIBSON COUNTY AUDITOR
Applicant(owne contact bu trktions rev side)
Toxin stn t Key number/legal description{,(�_,�L`, Record limber Page number
property 9 - 11-ts-aoa- oDI .sl -► -oa'7 ro X106
Assessed value of real property as Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,Cgu�nt year date of application legal or equitable owner?
/VY`)/V�1 at ❑ Yes Ill 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 or contract seller ® ;
Address of mortgagee or contract seller(number and street,city state,and ZIP code)
Name of assignee or other owner or holder of mortgage Cr e, \ 1 Q. L.. �OG-
Address of assignee(number and street,city,state,and ZIP code) `* OU` `A��
O �1 }
Does applicant own property in any If yes,what county? What Taxing t aO`t' — \\ b Gate amount of deduction
other county '_•11_\O
in Indiana? ❑Yes ❑No F
me
A person is not entitled to this deduction unless the person has a balance i ;,.() le O 0 is recorded in the county
recorder's office(including any home equity line of credit that is recorded ii, _ __. ......,.,;duction.
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
I/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.
Signature • nets full name) //% Dare nth,day,year)cigoiartz / L 45— I40
sident addre s of applicant(numberand street.city,slat d ZIP code) n
5q. i,J .So S :A C nsi . L{71070
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 510,000.