HomeMy WebLinkAboutMortgage_Whitehead (3) P. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
GlFOR DEDUCTION FROM ASSESSED VALUATION
, State FOml 43709 Department o 1Presabed by Department of Local Government Finance
INSTRUCTIONS:
lb be filed in person or by mail acv ff�cf with:
Filing Dater 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought JUL 1.17j Tor
Must be filed or postmarked with the County Auditor or County Recorder of the county where the properly is Li County Auditor
located on or before January 5 of the immediately succeeding calendar year. � •• Recorder
2) Mobde/Manufactured Homes not assessed as Real Properly:Must file with the County Auditor of the •• YI,r , • 7�❑ -•R
where the property is located during the twelve(12)months before March 31 of each year the ded .,
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See reverse side for additional instructions and qualifications. ' •UNTY AUDITOR
Applicant(owner or ct on reue fie) /�
i �_~ C e 4T
Taxing District 6 a3-ter i too-O DI. 0 8 ') -oa Record 1(number P number D ,
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 date,current year assessment date, mment r date of application legal or equitatie owner?
4 (pr 0 Yes 0 No
If in what is his l 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
D.Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller l f
Address of mortgagee or contract seller(number and street odtP,state.and ZIP code)
Name of assignee or other owner or holder of mortgage
-
Address of assignee(number and street city,state,and;
Lk)
Does applicant own property in any If yes,what county � �y' n been requested If yes,state amount of deduction
in iana?ly ❑Yes ❑No 1 ' ❑Yes ❑No _
A person is not entitled to this deduction unless the retract indebtedness that is recorded in the county
recorder's office(including any home equity line of. l i ' )3I)() that is the basis for the deduction.
Deduction approved in the amount of (O Os
20 20 20 20 20 20 20 -
Signature of County Auditor County - Data(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
er/contract buyer of the aforementioned property on date application is filed.
(owner`s hre name) (n.wnh,day,year)
1nd&�</ . IJf�.. ..p —la-ly ere
ident dress of applicant(number and street city,state,and ZIP code)
saaa 6 , goo s C k17a,5
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 two and a half years and a fine not to exceed$10,000.