HomeMy WebLinkAboutMortgage_Goldsberry (2) iSTATEMENT OF MORTGAGE OR CONTRA I T!3 County I Township I Year
t-°a_ FOR DEDUCTION FROM ASSESSED VALUO LI g/'
State For 43709(R12/6-14)
\ � m Prescribed by Department of Local Government Finance 4 201
MAR 1 2016 INSTRUCTIONS: 6 File Mark
To be filed in person or by mail. Form tiled with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year!.4I i' li � tq y;!t tion�is wsyo�ueght.
Must be filed or postmarked with the County Auditor or County Re - • .7. 1 a i cnf-property is 7 County Auditor
located on or before January 5 of the immediately succeedi�B$®D� I U County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of 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.
Applicant(owner atclfirra ct buRRr-i see re7td^fion�rse sid
Tax' Dis ct Key number/legal description Record number Page number
el f t ab/V-/S- 00�l- 000 J/3 -cV7 ao/5 /KZ,
Assessed value of real property s of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March ._curuRnt yeah date of application legal or equitable owner?
(/O 9 O ❑ Yes ❑ No
1 If no,what is /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)
1Name
street,city,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 applicant own properly in any If yes,what county? 1 What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on properly 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 deductions
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County 1 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 owner's full me) 1 Date(month,day,year)
3— /4—/C
till resident ad . of applicant(numbe and street,city,state and ZIP code)
31 ,T WFYI tf� PCti01 CI1-1 �l� c-126 ‘ 0
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.