HomeMy WebLinkAboutMortgage_Simmons (3) RY" , ' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
1, \ FOR DEDUCTION FROM ASSESSED VALUATION T 2016
s P State Form 43709(R12/6-14) FILE
'o�w Prescribed by Department of Local Government Finance File Mark
feu
INSTRUCTIONS: JUN 1 216
To be filled 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 County Auditor
property is located on or before January 5 of the immediately succeeding calendar year. • M �1 ry
2)Mobile/Manufactured Homes not assessed as Real Property: Must file with the Cif gr1QQ(7 TY AUL/ITUR County Recorder
county where the property is located during the twelve(12)months before March 31 o ea year he
deduction is sought.
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Jesse A. Simmons, Diane J. Homby, and James C. Homby
Taxing District Key number/legal description 26-18-13-401-000.716-026/505 N West St., Record rulm_ber Page number
�{2)/Cp-..C'/C/ Fort Branch, Indiana 47648' ( f[J a 33
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?
$123,300.00 gales ❑ 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 -
Regions Bank d/b/a Regions Mortgage
Address of mortgagee or contract seller(number and street.city state.and ZIP codel -
2050 Parkway Office Circle, Birmingham,AL 352 t�CQ A C rim OAS
Name of assignee or other owner or holder of mortgage iE.,y i-t W-+, '
. D1u1 --I d �q/n(3 C.
Address of assignee(number and street,city,state, and ZI
cn3y
Does applicant own property in any If yes,what cot. /Ca — Lug t been requested If yes,state amount of
other county deduction
in Indiana? ❑ Yes ` CNo _ 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 penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner-4-eoMFact buyer of the aforementioned property on date application is filed. .
gnature(owner'.ull name) - Date(month,day,ye 4
� % 6-9-'l
FLIT regident address of 2pplicint-(rwmbasr and street,city, state,and ZIP code)
505 N West St., Fort Branch, IN 47648
Person authorized 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 Iwo and a half years and a fine not to exceed$10,000.