HomeMy WebLinkAboutMortgage_Smith (37) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
f FOR DEDUCTION FROM ASSESSED VALUATION
t,1 �'. State Form 43709(RI3/10-15) +
`- Presalbr.M by Department of Local Government France ;�)
INSTRUCTIONS: ...AAA ' rte Math
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To be filed 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 sit 7 ZQ is
Must be filed or posbnarked with the CountyAudtor or County Recorder of the county where thW`property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year d County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor the ••1••-ei
where the pmperty is located during the twelve(12)months before Mardi 31 of each year the 0.dl,::;..etittr}.
See reverse side for additional instructions and qualifcattons.�y�n� /L C,tRSON COUNTY AUDITOR
Applicant or conlractbryer-see onreside6
Taxing strict i mbar/legal description Record number Page number
'�f � aP - /9-f9 - X0,3 _ 60/. 01 .35 -0;-4 ; or 2 d 9 ,
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment des,current year assessment date,current year date of application legal or equitable owner?
/2. S oo&) ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other t(an spouse,indicate with whom
H name on record is different than that of applicant indicate belay. Is the property in question:Annually Assessed
❑ Real Property ❑ AnnuallyAssessed
• Mobile Home(IC 6-i.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and sheet city,state,and ZIP code)
Name of assignee or other comer or holder of mortgage
Address of assignee(numbs and street illy,state,and ZIP code) .
Does applicant own property in any If yes,what county? What Taxing District? --_ I Has this deduction been requested I If yes,state amount of deduction
other county cunr ❑i Indiana? Yes ❑No rrrenty irk _C)Kin_ -- - - — -
A person is not entitled to this deduction unless the person has a balance on the pc 1 E`�\V�fr orded in the county
recorder's office(including any home equity line of credit that is recorded in the cm 3„v ,y., �1- 3x,u` m.
COUNTY AU c ` i A \o Es—K (-0 ,
Deduction approved in the amount of
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20 20 20 20 �l�— aa� � (o\b-lc, 20
ig \a'3 1UDO
Signature of County Auditor Ca..., I 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.
SignaWr d aeYS full name)C. Date(month,day,year)
kb.../ Cl�
Fug r address of apprxant(number and street aly,state.and ZIP code)
4......
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Data(month,day,year)
Address of authorized person (number and street city,slate.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.