HomeMy WebLinkAboutMortgage_Head (3) = STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS hip I Year
°e FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R12/6-14)
•'� �' Prescribed by Department of Local Government Finance r
INSTRUCTIONS: APR, ZU rlY 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 deduction is soug
Must be tiled or postmarked with the County Auditor or County Recorder of the county where th � ' ounty Auditor
located on or before January 5 of the immediately succeeding calendar yeas �1 `rQ� TY Al.Dunty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Y
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought —
See reverse side for I instructions and qualifications.
Applicant(owner o t -see frictions on reverse side)
njn d S /12611:231
Taxi Distn t ��,• �y1 I Key number/legal description Record number Page number
/ C a4,-0'71-.2 5- /O/-000 , 075Uaa 40/62 /076/
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 12,current year date of application legal or equitable owner?
(35 `955 ❑ 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 mo a or,contract el er
Address of mortgagee or contract seller(number and street,city,stale,and ZIP code)
Name of assignee or other owner or holder of mortgage /�'� A
Address of assignee(number and street,city,state,and ZIP code) '-' "K/u__'
Does applicant own property in any If yes,what county? What Taxi; /(O"/ot 4', :,state amount of deduction
other county
in Indiana? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balan at is recorded in the county
recorder's office(including any home equity line of credit that is record[ deduction.
• COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 I 20
•
Signature of County Auditor 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.
Signature(owners full name) Date(month,day,year)
Y rr"Q r.-.t1 a ) CA. A
Full resident address of applicant u ber and street,city stare.and ZIP code)
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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 S10,000.