HomeMy WebLinkAboutMortgage_Davidson (2) t ^4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
= :i FOR DEDUCTION FROM ASSESSED VALUATION �`
s L` State Form 43709(R12/6-14) - 1
•‘ ,m. 1 Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS:
To be filed in person or by mail. JUN 8 2016 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 ❑ 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 with the County Auditor
where the prop s located during the twelve(12)months before March 31 of each yea d B&Vbtt6QtJS4d AtAU JITOK
See re e side for additional inst tions and alifications.
Appli. wner or cony9c�fb er-se restrictions n reverse side) n - �' ,,
A� a/ Lo-(!a% / J 0nx-( r
i- ' bid • Key nu ber/legal desdd ion (. � ber Page number
o
A,� �'-��i�- 4�)% - 6 �.� - 5 a 7� ad 59
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/ tract indebtedness unpaid as of Is the applicant the sole
March 1,accent year March 1,anent year date of app ca legal or equitable owner?
/ 0764; °° ❑ 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 property in question:Annually Assessed
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller i, 4/C,l/ dst� "
Address of mortgagee or contract seller(number and street,city,stade)
Name of assignee or other owner or holder of mortgage .
Address of assignee(number and street,city,state,and ZII
Does applicant own property in any If yes,what county? rested If yes,state amount of deduction
other county ❑Yes V. \r., ( SO 11
in Indiana? El ��C�-".S (`� 0 N
A person is not entitled to this deduction unless the p J a,•k ` 'ebtedness that is recorded in the county
recorder's office(including any home equity line of or basis for the deduction.
* u ( f Ci Q t ptaOS .oc)
Deduction approved in the amount of: (42— 16—It-:7
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.
Signature /s full name) Date(month,day,year)
Full resident address of applicant(number and street,city,state,and ZIP code)
X /O 2,3 S- Sfor,rlonli" S/ree t errtiGeiSrJ, IA) 4,7 6 7Q
1 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.