HomeMy WebLinkAboutMortgage_Ross o STATEMENT OF MORTGAGE OR CONTRAC ! `Ii9rEDE$ County Township Year
irc 44) FOR DEDUCTION FROM ASSESSED VALUA ti •N AF-1
i - State Form 43709(R12/6-14) y
' Prescribed by Department of Local Government Finance
MAR 2 2016 File Mark
INSTRUCTIONS:
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 ich.the edu on' ught.
Must be filed or postmarked with the County Auditor or County Re where the property is ❑ County Auditor
located on or before January 5 of the immediately succeecabaSajt4a0,,mtuv in County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must fit With-tie Cot rryr+uwurof the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought '
See reverse side for additional instructions and qualifications.
Kristy D. Ross
Taxing District Key number/legal description Record number Page number
Haubstadt Township 26-19-31-304-000.356-009 ( lQ -1-12
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,anent year March 1,current year date of application legal or equitable owner?
72000.00 p 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 or contract seller
German American Bancorp
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
P.O. Box 360, Jasper, IN 47547-0360
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city.state,and ZIP code)
Does applicant own property in any If yes.what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county „ property for
in Indiana? ❑Yes ❑No current year? ❑Yes ❑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.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signs:.'- 4 Coun Auditor Coun ,) Date(month,day.yearrl'1'11
a certi fy under the penalty of perjury that the a.•ve 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.
Signal (owner's hdl name) Date(month,day,year)
() 0Q- ? )--Dona
Full resident address of applicaCntt(number and street,city.state,and ZIP code)
208 S. Second Street, Haubstadt, IN 47639
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$10,000.