HomeMy WebLinkAboutMortgage_Haase STATEMENT OF MORTGAGE OR CONTRACT INDEBTEEEES
>.o lA NV/� Township I Year
;e__ f FOR DEDUCTION FROM ASSESSED VALUATION
• State Form 43709(R12/6-14)
Prescribed by Department of Local Government Finance MAR 2 9 2016
INSTRUCTIONS: File Mark
To be filed in person or by mail. .r Form filed with:
a 1l;m1h
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the dedu •,fin . p 11TOR
Must be filed or postmarked with the County Auditor or County Recorder of thG�ntafil fa 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 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(ow r contract bu er-se restriciio s o reverse a side) .,
T Dist"ct 'Key number/legal description Record number Page number
on.-71" a /0.-/o -30 egoo mi. 35 9 o c / apt (x. 1 1 (03
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 Ma/6/-
1, nentyear d to of application legal or equitable owner?
�� �} Y//l1 ❑ Yes ❑ No
If no,what is his/her exact share of interest?//tvr 4 e ao i. caned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: ssib
,Ie property in question:Annually Assessed
Jam'Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or s II L� _ _ /.
Address of mortgagee or contract seller(numbeerJand��street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage _
Ji� L. � •- sli. So4•Address of assignee(number and street,city,state,and ZIP code) •
T-C�...e\\v.C. S.�(KtQse 1
Does applicant own property in any If yes,what county? i \ l 1/'S` ` I A' p \ :ed If yes,state amount of deduction
other county —Tv-us k "C) 1V z: l r—o-1 No
in Indiana?
A person is not entitled to this No deduction unless the person %G'w� ' l��0 v 0 O a • d - 4edness that is recorded in the county
recorder's office(including any home equity line of credit th 'ac) l e - l 1 I 3 - IQ_I r Isis for the deduction.
. COUNTY AUDIIvn I lc .
Deduction approved in the amount of:
20 20 1 20 20 20 20 20
Signature of County Auditor 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 aforementioned property on date application is filed.
Signature(own ulI name) Date(month,day,year)
(Full resident address of applicant(number and street,city,state,and ZIP code)
`Person authorized by duly executed Power of Attomey 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.