HomeMy WebLinkAboutMortgage_Dame STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
} FOR DEDUCTION FROM ASSESSED VALUATION YCounty Township Year
State Form 43709 Department o gp D
Prescribed by Department of Local Government Finance g
INSTRUCTIONS: lg g XX�� File Mark
lb be filed in person or by mail. II''II II gc) f, 16 Fortn filed with:
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which thaihtluc86rYis ught ttt���ttl
Must be filed orpostmariced with the County Auditor or County Recorder of the county where the • •per is County Auditor
located on or before January 5 of the immediately succeeding calendar year. .i County Recorder•
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with th;W:-nr'9.11471. the county
where the property is located during the twelve(12)months before March I 1 ofd Z- + efge¢pgQTS3t�ght
See reverse side for additional instructions and qualifications. BS
Applicant(owner or buyer-see msbi ore rse side) /� �,,
/�m�n�traefpr/�^1'�vvLe� .. anu t 1 t- CJ lQA JSQ�n L
1 Key number! at description —r Record minter Page number
4-ao ae- -660-Ida 'OO/ 10 3110 _
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 current year date of application legal or equitable owner?
3Ox0 ❑ Yes ❑ No
If no,what is his/her exact share of interest? i If owned with someone other than spouse,indicate with whom
If name on record is efferent than that of applicant,indicate below: Is the property in question:Annually Assessed
❑ Real Property ❑ AnnuallyAssessed
- • Mobile Home(IC 61.1-7)
Name of mortgagee or contract seller
La ^ ^ ,
Address of mortgagee or contract setter(number and street city, J\state`,,-✓aFnd ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city state,and Zt
Does applicant own property in any If yes,what county? r requested If yes,state amount of deduction
other county r11
in Indiana? ❑Yes ❑No r V I Li s ❑No _
Drawer NO
-
A person is not entitled to this deduction unless the p - it indebtedness That is recorded in the county
recorder's office(including any home equity line of a r-3-14 2 ( I o :the basis for the deduction
Card NO. V1
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of Auditor - / County - Date(mina,day,ye
AL.11- _data_ / . . a _.I. is i 07 /.L
11 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.
Signatu - a,.: JO name • Date( riM,day
— 7/2r
resident address of applicant(number and street oily,state-and ZIP code)
\ R372 £ 900 S 4lbrr'tld -12-- N 47L I3
Person authorized by duly executed Power of Attorney or by IC 61.1-12-0.7 / '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.
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