HomeMy WebLinkAboutMortgage_Hartley (6) STATEMENT OF MORTGAGE OR CONTRACT 111ji EiTDN , aunty Township Year
t'- FOR DEDUCTION FROM ASSESSED VALUATI Il `
'- State Form 43709(R13/10-15)
Prescribed by Department of Local Government Finance S E P 9 2016
INSTRUCTIONS: File Mark
To be filed in person or by mail. 'Form filed with:
Filing Oaten 1) Real Property Must be completed and dated in the calendar year for ,r{,13,...,414,..44,, "s sought r—v
Must be Wed orpostniarked with the County Auditor or Co t , • 4 It ,f perry is County Auditor
located on or before January 5 of the immediately succeeding.:�".:" �. County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought - _
See reverse side for additional instructions and qualifications.
App&2nt(owner or contract dryer-see restrictions on reverse side ) '
C9� �74n1464
Ta' number/legal Red number Page number
7 Sri a -is - /K- 0203- 0007 . 1.2cQ - o-zCi---) ao/ A9/ 7
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
/Q ,359 / ❑ Yes ❑ No
If no,what is his I 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 property in question:Annually Assessed
eal Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mo or contra seller
Address mortgagee or co seller(number and sheet,city,state,and ' -V/ ---c-Cr t
Name of assignee or other owner or holder of mortgage U V�"�\Qr - ( e(C
oIci.— �� 11 ( � 'r I
Address of assignee(number and street city,state,and ZIP code)
X03,- ( I .�Z -1-0202-x.
Does applicant own property in any If yes,what county? What Taxing District? If yes,state amount of deduction
�ndiaa? ❑Yes ❑No cuurrenttyyear? Ll rca _. _
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 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 filed.
Signature(owner's full name) Date(month,day,year)
7 °rwies pc� (9- 9 -
Full resident address b ant(nuts andrOneet,city,sate,and LP code) of
7C /&/7 .S �) n ���lcc a tJ
Person authorized by duly executed Power of Attorney or by iC 6-1.1- -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.