HomeMy WebLinkAboutMortgage_Clark (5) �v STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count Township Year
;:t = FOR DEDUCTION FROM ASSESSED VALUATION
. j i' State Form 43709(R12/6-14)
Prescribed by Department of Local Government Finance , -rte I�
rt rk
INSTRUCTIONS: - ll
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 s DD cc
Must be filed or postmarked with the County Auditor or County Recorder of the county where the prop*rty i2O1U ❑ County Auditor
• located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Audi el tf the c.•my
where the property is located during the twelve(12)months before March 31 of each y ct(le ..A%:t•.—j;yr.
See reverse side for additional instructions and ualifications-n���ry �i tl°ON C
Applicant(o i ....taacctt buyer-sere/�(pJS/*ctiioonns on reverse sidgl OUNTM dU�)T�R
an
Taxing Distri•.� / Key number I legal description Record number Page number
Ala • ctnc4.5 26-/3.00-/03 - n-aoj/n?- c k5 /6 513
Assessed value of real property as 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?
'/OLC/v ❑ 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
teal Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract sel 77-7-C.
Address of mortgagee or contract seller(number and street.city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
C L ARAC CT,
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any If yes,what county? Taxing District? + I :auction
other county ❑
in Indiana? ❑Yes No
A person is not entitled to this deduction unless the person has a balance on the person he county
recorder's office(including any home equity line of credit that is recorded in the county r
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor 1 County Date(month,day,year)
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 aforementio ed property on date application is filed.
Signature(owner's full name) / O 3 1/ Date(month,day year)
Full resident address'hf plicant(number and st et,city,state,and ZIP Vcod/Ve)(_.. //
oaks ( - i ��. y76ti Of
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 S10,000.