HomeMy WebLinkAboutMortgage_Scott �, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
= > FOR DEDUCTION FROM ASSESSED VALUATION FILE
eop' State Form 43709(R13!10-15) p jgty��'
Prescribed by Department of Local Government Finance Yp e-K7�C
INSTRUCTIONS:
lb be filed in person or by malt. SEP rm sled with:
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought 1 4
Must be filed orposbnarked with the County Auditor or County Recorder of The county where the property is tounty Auditor
located on or before January 5 of the immediatety succeeding calendar year. County Recorder•2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Audi of the, y
where the property is located during the twelve(12)months before March 31 of each year the
See reverse side for additional instructions and quaffcations. TY AUDI Top
Appliant(owner or contract buyer-see restrictions on use side) -
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T '' D / description Record`�"'��' Page mbar
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Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/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?
/ 3 i a-0 O ❑ yes ❑ No
If not 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. - °2 C)l lc - 3 0�6
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Name of mortgagee or contract seller ` el Q-. $(- a� 1. Co `O'N(B C� —
Address of mortgagee or contract seller(number and street city,state,and ZIP code) 13 i ■
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Name of assignee or other owner or holder of mortgage
Address of assignee(number and steel,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 deduction
other county on property for
in Indiana? ❑Yes ❑No anent year? ❑Yes ❑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 line of aedit that is recorded in the county recorders 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)
!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.
ek Sigrwture e.. .. / 2 Date(month,day,year)
Fug resident address of applicant(number and sheet'dfy state,and P e)
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Person authorized by duly-executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
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The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 510,000. .
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