HomeMy WebLinkAboutMortgage_Michel (11) °&nc STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
•1 1 FOR DEDUCTION FROM ASSESSED VALUATION F I T J F D
IB State Form 43709(R12/6-14) �-i Y8 Jtl
„„�< Prescribed by Department of Local Government Finance
INSTRUCTIONS: MAY 4 2016 File Mark
To be tiled in person or by mail. Form filed with:
Filing Dates: 1) Real Properly: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 ywhe the ertyis County 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(v{mgina .74r
where the property is located during the twelve(12)months before March 31 of each year the deck/68:W deck/68:W right.
See reverse side for ad '' nal instructions and qualifications.
Applicant(owner or con U b r see resSiC{ns}on " e) o�
Toxin Di G ey number ll /V//7`' Record number Page number
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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 yea') / date of application legal or equitable owner?
❑ 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 mortgagee or contract seller _ 9 /� r)
•Address of mortgagee or contract seller(number and street,city,state,and ZIP code) 'C.��'
Name of assignee or other owner or holder of mortgage
Address of ar'///1yyy��l([/,`{
n
Does applicai _ om District? Has this deduction been requested If yes,state amount of deduction
other county � ��/1 on property for
in Indiana? U><-'��"- I r r current year? ❑Yes ❑No
A person is r on the person's mortgage or contract indebtedness that is recorded in the county
recorder's of _ z (I ?the county recorder's office)that is the basis for the deduction.
Io -Jq//� 'MY AUDITOR .
Deduction apt
20 I 20 20 20 20 20 20
I
5ifikozyx_....)
Signature of" u i. Auditor /
r• / County Date(month,day,year)
I/ e 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.
Sit nature(pees hrlloyme) Date(month,day,year)
Signature
reside address of applicant(number and street,city,state,and ZIP code)
)&1 0 8 R ?-5o S gr r drr,rcis A/ y-76 9,7 •
Person authorized by duly executed Power of Attomey 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 510,000.