HomeMy WebLinkAboutMortgage_Nielsen (2) •rr.no STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County I Township I Year
FOR DEDUCTION FROM ASSESSED VALUATION
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.{ " State Form 43709(R12/6-14)
-_-- Prescribed by Department of Local Government Finance - -- ma-
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INSTRUCTIONS:
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To be filed in person or by mail. Form filed with:
Firing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. ¢t1st
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is APR al tntuty 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 sou'9 --i �r
See reverse side for additional instructions and qualifications.
Applicant(owner or co tra t buyer-see restricjiops on rseside)
Taxing District Key numbbeer/legal description Recoid number Page number
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G- ILI' a0 - ace -coo 7/21 - 00(0 x)/( 9 ( J) b
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,current year March 1,current year date of application legal or equitable owner?
C. 3 '01-b ❑ 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 properly in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contact seller -
Address of mortgagee or contract seller(m _--.---------------
Name of assignee or other owner or holder
Drawer NO......
. .....
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Address of assignee(number and street,dl }/ _^�l7/7'���{�^� •
Does applicant own property in any If yes . Cat ,0. l •
\ •• lion been requested If yes,state amount of deduction
other county
in Indiana? ❑Yes ❑No El Yes El No
A person is not entitled to this deduction •••. .„,vii use 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.
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COUNTY AUDITOR .
Deduction approved in the amount of:
I 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
o er/contract buyer of the aforementione. .ro.e • date application is filed.
n lure(owners namm�� Date(month,day,year)
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r ident a r of a licant(number a street, .. state,and ZIP code
l \ N 1 -oo E gib L12 Cote 0
Person auth ed by duly executed Power of Attorney or by IC 61.1 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$10,000.