HomeMy WebLinkAboutMortgage_Winstead (2) R•n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
2`}s°a
1.- -`7-._4} . FOR DEDUCTION FROM ASSESSED VALUATION
"tit State Form 43709(R12/6-14) - _
1.?-.--,I.,:::S `' Prescribed by Department of Local Government Finance MM. ; ! i� ,•.�
'Fit: M-
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 sought.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is AP f ► O y Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not a essed 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 sou•'j yrij;
See reverse s'•e for additional instructions and quali ations. f;IRSnr4 CntiNTY Al InITOR
Apprise • er or contract buyer-see res ' . son e�sidd) /�
LPL, C,/r/
(9 f��� e
Taxi••^trict f Key number/legal desorption / Record number Page
f . A. ,�� �7-log - o -dog � 6a f �o /3/
..--•value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness un rd as of Is the applicant the sole
1,anent March 1,current year date of application � legal or equitable owner?
r / V d ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than s'•use,indicate with whom
If name on record is different than that of applicant,indicate below: ls e property in question:Annually Assessed
l ® Real Property ❑ Annually Assessed
/ (X .1 / 1 Mobile Home(IC 6-1.1-7)
Name of mortgagee or contact seller J
Address of mortgagee or contract seller(number and stree ,state,and ZIP code)
Name of assignee or other owner or holder of mortgage //��
•
Address of assignee(number and street,rill:state-= � n az/ /0 d,✓ -
Does ones. U ( L ••'• cal Taxing District? Has this deduction been requested If yes,state amount of deduction
..• on property for
it \O•• anent year? ❑Yes ❑No
A I Q l'l�s el { I ersrtgage a indebtedness is in the county
res•
.. ••''•• ;obalance rded in on the the p countyon's recordmoers offior ce)contr that is ct the basis for the that deduction.recorded
Ded
C11 d \O• COUNTY AUDITOR .
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20 20 20 20 - 20
1
Signature of County Auditor County Date(month,day,year)
412) 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 of rementione¢'property on date application is filed.
NC g!9i ) Date(month,day,year)
G
i
Full resident dress of applicant(nun r an treet,city,state and ZIP e) L �1
i S D r)� �- „L0s7ultc{l , Z,� t)7/ 7
Person authorized by duly executed Power of A ey or by IC 6-1.1-12- 7 Date(month,day,}rear)
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$10,000.