HomeMy WebLinkAboutMortgage_Cooper a, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
'r` FOR DEDUCTION FROM ASSESSED VALUATION g , '
U. State Form 43709(R13 f 10-15)
- Prescribed by Department of Local Government Finance
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INSTRUCTIONS: File Mark
lb be filed in person or by mail. SEP 9 Fed 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 property'. ❑ Coun Auditor
located on or before January 5 of the immediately succeeding calendar year. ri
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor .,/,: '�'!)!!:''County Recorder
where the property is located during the twelve(12)months before March 31 of each year the der>�° .t' N rY AUDITOR
See reverse side for additional instructions and qualifications.
Applican wneror contract buyerseeresyicdons verse side)
Taring D /Ke`yy nnumber/legal 1 plion Record number Pagenurl�ber to
0/Z G!/�Cd amp — /3 - - - all( - OOO. / 07 - 005 fl(.0 3/!�s
Assessed value of real property as of Mortgag= Contract i,.ebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole •
assessment date,arrant year -- - -,cortent year date of application legal or equitable owner?
SgooD ID Yes 0 N
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
n Mobile Hone(IC 6-1.1-7)
Name of mortga a contract seller �i le A .
Address of mortgagee or contrail seller(number and street idly,state.and ZIP code) �(i �V l
Name of assignee or other owner or holder ofmorigag Drawer NO 9 , y
Address of assignee(number and street city,state,as ` - .
Card NO. ' `J C.)
Does applicant am property in any If yes,what con 1 been requested If yes,state amount of deduction
other ❑Yes 0 N DYes 0 N _
A person is not entitled to this deduction unless um ye,a», _.._._ mired 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 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 teed.
X /
S' r0( e) Date(month,day,yea)
�Fu1 y' t address (number and st street city; .and ZIP code) (�1
'\ IO'� ..17 SCE f%L(Ca r YIr'te.0 GI `i"/&-, 9
Person authorized by duly executed Power of Money or by IC 6-1.1-12-0.7 Date(month,day,yea)
Address of authorized person (number and sheet 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.