HomeMy WebLinkAboutMortgage_Harmon (5) a'°^*v STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
. State Form 43709(R1216-14)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: g - -- i - File Mark
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 de 6asou
Must be filed or postmarked with the County Auditor or County Recorder of the cou�dfe therpoperty is U.—eounty 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 Co Audit of my
where the property is located during the twelve(12)months before March 31 of each is sought.
See reverse side for additional instructions and qualifications. r;;DSON COUNTY AUDITOR
Applicant(o r contract buyer wee
'Record number Page number
I ac - os-'-}-Oo -ooi.8so -oa, ao16, Si ?--
Assessed value of r I property a o Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Mardi 1,current y March 1,current year7f80000 date of application legal or equitable owner?
❑ Yes ❑ No
If no,what is his/her exact share of interest? / If owned with someone other than spouse,indicate with whom
1 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 mortgag or contract seller A a.0 l..Y.J k-d u 1 �f —
U —
Address of mortgagee or contract seller(number n . et,city,state,and ZIP code) �/ --
./ (ariplen V �t 1�
Name of assignee or other owner or holder of mortgage �' 1 f`�
3 - 5 -/cam 75sy f
Address of assignee(number and street.city,state,and ZIP code)
�O/We
Does applicant own property in any If yes,what county? What Taxing District? Has O/4 --- e - to
other county on p
in Indiana? ❑Yes ❑No • current yearn ,—. .
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness Mai,a,.,_... ounty
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 I 20 20 20 20
Signature C my uditor '1 / County y/'��'^ Date(moot da .yearr)1)
,We certify under the pen>.._..
Ity of perjury that the a�tty foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property nn to application is filed.
gicit:elefr.".2^y. ure(owners full name) Date(month,day,year)
ead t applicant number and street,city,state,and ZIP node)
678 4+ S5b3 OU e.,.su%//A- z// 1-17G4 f
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.