HomeMy WebLinkAboutMortgage_Presnal •°�"v STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
Q_ _. : FOR DEDUCTION FROM ASSESSED VALUATION
l State Form 43709(R12/614)
. e• Prescribed by Department of Local Government Finance
FILED 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 which the deduction is sought.
Must be filed or postmarked with the County Auditor or County Ri�i�%5yr{{{{peri�QQf th �gypty where the properly is County Auditor
located on or before January 5 of the immediately succeeding cal�id'or yrear. L 10 ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before.rch 31 f ea c year a deduction is sought.
See reverse side for additio /II ins ructions and qualificatic C
Applicant(owner or contras uy€r- re coons reverses GI$SD • .frTYAUDITOR
Toxin aMc 'in Key number/le al descri tion f' Record ber Page number
• a� �a-o3-30o 00 a(q_ O 7 �� C79�
Assessed value of real property s of Mortgage/Contract indebt dness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1.current year March 1,current year j5'Q Q date of application legal or equitable owner?
(�LJ(� ❑ 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 /j
4
Address of mortgagee or contract seller(number and street,cif 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)
Does appl t Taxing District? Has this deduction been requested If yes,state amount of deduction
o Indian ' /)(2 C G 0 fl L. /x,t n Z . .-S J� on property for
in Indiana' r 7t �J CA -� current year? Li Yes ❑No
A person c 14 My L 4 valance on the person's mortgage or contract indebtedness that is recorded in the county
recorder; l• 7 corded in the county recorder's office)that is the basis for the deduction.
C is eiRyc COUNTY AUDITOR
Deduction I
20 I ' 1P9& 20 20 20 20
Signature of Count ,r f County Date(month,day,year)
_dA i / _ :Sit..—/ •
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 w ers full name , Date(month,day,year)
a,lr�-fir .
ull reside add ss of applicant(number st et,city,state,and ZIP code)
909 0J. ails E . iocL-tea -V. 'f7( l
Person authorized by duly executed Power of Attomey or by IC e-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.