HomeMy WebLinkAboutMortgage_Hornby a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE . onship Year
4!._-tri, FOR DEDUCTION FROM ASSESSED VALUATION ICL4nblE
..,-...P,:, .1.=:- State Fonn 43709(R13/10-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: SEP 9 201Efile Mart
To be filed in person or by mail. Form MS with:
Fliing Dates: 1) Real Property Must be completed and dated in the calendar year for which the deduction is , lit , ,__,
Must be filed or posbnarked with the County Auditor or County Recorder of the county wire U County Auditor
located on or before January So!the immediately succeeding calendar year DiTa County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the COA14§0 tgfiltiltiWtyAU
where the property is located during the twelve(12)months before March 31 of each year the declucllon is sought
See reverse side for additional instrudions and qualifications.
Appl t(owner or contract buyer-pee --, -'.. on reverse side)
Taxing, labia Key number/legal••-•a. Record number Page number
74(3-4---0-4-4.67:4-t- 7, C., - )-k. - 0 ct. - (0 3 - a oo . 4,82.5-00? .2 or co 3 o 3 6,
Assessed value of real property as of Mortgage I Contact indebtedness unpaid as of Mortgage!Contract indebtedness unpaid as of Is the applicant the sole -
assessment date,current year assessment date,current year date or application legal or equitable owner?
( Li Cll °49 ° 0 Yes El No
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
- -_ ___I aReal Property 0 AnnuallyAssessed
• -_ _Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and street ctly,state,and ZIP code) 0207.„
Drawer NO.
Name of assignee or other owner or holder of mortgage
Card NO. .......
Address of assignee(number and street city,state,and ZIP code) .......... .
Does applicant own property in any If yes,what county? Mat Taxing District? Has this deduction been requested If yes,state amount of CleciudiOn
other county ,—, on property for ,
in Indiana? U Yes 0 No current year? LJ Yes 0 No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity fine 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:
zo 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 coned and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
FS TIE re(owner's fullnanA9, Date(month,day,year)
1\ ' it
r F resident ad ess of appficant mber and street,city,state,and ZIP code)
`‘ 1-1/3 i A IN AC, 164 44 e_S-7);07 GA/ '171039
Person authorized by duly executed Power&Attorney or by IC 6-1A-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet My,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a haff years and a fine not to exceed$10,000.