HomeMy WebLinkAboutMortgage_Willis (2) <o r STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
' :_;G FOR DEDUCTION FROM ASSESSED VALUATION
State rtbed 43709(R13
Department ment o FILED
Cl---.-- / Presrnbed by f)epaMreM of Local Government Finance
bVSTRUCTIONS: File Mark
- To be filed in person or by mail. II ( Form filed with:
Filing Dates 1) Real Properly Must be completed and dated in the calendar year for which the dell lon1iso agr 9�1�S
Must be hied or postmarked with the County Auo County Auditor or County Recorder of the county where the property is ' El-Monty Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile helpa��is located during the twelve(12)months before Must file the _:l .?e p i s county t.
where the �1 g3 r
See r verse side for additional instructions and qualifications.
r;ht • - orconba buyer- ->- re -rse side)
4 _lam ' OA _ - Jr,'.,;. i l (,QQc C, number
..y. :r6 . / f 0�0�% -051 W 001/4. 751-Od 1 /(o WIZ
Assessed value r - property Mortgage! 'ndebtedness unpaid as of Mortgage!Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year d7 • date of application legal or equitable owner?
/ .OW ❑ Yes 0 N
!too,what is his!her exact share of interest? If owned with someone other than spouse,indicate with whom I
If name on recall 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 . . I //..
• � . Akio L _
Address of mortgagee or contract seller(number and street till:stale,and ZIP...--)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street cdy,state,and ZIP code)
Does applicant own property in any I If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
o'. - __ on property for
it � pp � -,, ,- _ anent year? ❑Yes ❑No
AT. LI l l0) CUT CI satj son has a balance on the person's mortgage or contract indebtedness that is recorded in the county
n: lit that is recorded in the county recorder's office)that is the basis for the deduction.
-- ��
COUNTY AUDITOR
is
-- I (n -11(10
20 ✓/� 20 !ti 20 20
_
li L Signature ./ Counry Date(moU a / a l J- /l/am L e . y l
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.
�igrWyre(av all am �\(�r n /� /��+ Date(month,day,year) i
I\/r/71AI rgsidegtpQ of a i numberan(Xd/~fstn �smte„anp LP A VA 11.
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Person authorized by duty executed Power ofSAttomey or by IC 6-1.1-12-0.7 �',V\ Date(month,day,year)
Address of authorized person (number and street city,state,and LP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.