HomeMy WebLinkAboutMortgage_Mayberry °^n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
r-- FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R12 l 14)
•' „„ 7 Prescribed by Department of Local Government Finance
INSTRUCTIONS: Fil jai
To be filed in person or by mail. ` • fit!�
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is soug . • •
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. /A�p��p 1,•. g,Eounty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the co1nry r
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 or ror�( e resbicuons ve side) GIBON R
\Tatting District escription Record number Page number
a& - 11 -01- L • tl1 -Da2, ,z or !y n3
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,aurreTaL date of application legal or equitable owner?
3 t OD ❑ 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:•Name of mortgagee or conct seller 26'i )
(� Drawer NO
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) Card�. �0
Name of assignee or other owner or holder of mortgage NO 4
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county , property for
in Indiana? Yes Iii 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 deduction.
COUNTY AUDITOR .
Deduction approved in the amount of:
•
20 20 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.
Sigpature(ow e/ name) � / J Date(month,day,year)
..cc(\X' number dd//�J
77 Id/ rh
i res a re of app rant number and street,city,state,and ZIP code)
Perso thorized 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.