HomeMy WebLinkAboutMortgage_Wagner (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
.e.7: ;` FOR DEDUCTION FROM ASSESSED VALUATION
till Sate Fonn 43709(R12/614)
o��/ Prescribed by Department of Local Government Finance
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 sotUt- 2 9 201
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. �J County Recorder•
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Audito ,.11� b •=l''flhr
where the property is located during the twelve(12)months before March 31 of each year ttl, d:i k -e tAU, •
See reverse side for additional instructions and qualifications. bt
Applica /o�wneer nor contract buyer a resttrriction5 on reverse side)
T 'n District�/r` Key number I I al description Record number Page number
na ?lc - 4 - 3/ � 303 _ 000. 3 , v-oo? 20/5 5 573
1 Asse value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of 15 the applicant the sole
March 1,anent year March 1,current year date of application legal or equitable owner?
l ' A D O D ❑ Yes ❑ No
If no,what is his I her exact share of interest? I 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 y 1 F(ti
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee•(number and ne city,state and ZIP code) / �r
Does appli nt own property in any If yes,what county? 'WWhatTaxing District? Has this deduction been requested If yes,state amount of deduction
other coun, I on property for ❑No
in Indiana? ❑Yes ❑No current year? ❑Yes
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
Signature of County Auditor I County 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 I contract buyer of the aforementioned property on date application is filed.
\ Signatyrej[►vner's full nre 1/ Da;e(month,day,year)
VC
en,resident address o apple nt •ber and t,city,state,and ZIP code)
/// 14 a Al X17- 9
Person authorized by duly executed Power of ttomey or by IC 61.1-12-0.7 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.