HomeMy WebLinkAboutMortgage_Morgan a... STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
.'°c: FOR DEDUCTION FROM ASSESSED VALUATION
W' State Fonn 43709(R13 110-15) 1.11
Prescribed by Department of Local Government Finance F I L p /
INSTRUCTIONS:
File Mark
To be filed in person or by mast. S E P 1 4 2016 Form filed with:
Filing Dates- 1) Real Property.Must be Completed and dated in the calendar year for which the dedudion is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the pro rty is lap County Auditor
located on or before January 5 of the immediately succeeding calendar year r ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the Co " county
where the property is located during the twelve(12)months before Mardi 3 roars &#J r)bEtfdc&*i®fit
See reverse side for additional instructions and qualifications.
Applicant owner or contraci buyer-see on use side)
r•. ' ...r. /f�ua,1
D'• ' Key number/legal . - o Record number Page number
•�._- .value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/ indebtedness unpaid as of Is the a
1 date,current year assessment date,current year date of application legal or quitable owner?
a ao pp C) ❑ Yes ❑ 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 appkant,indicate below: Is the property in question:Annually Assessed
❑ Real Property ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contras 1err.
Address of mortgagee or contact saner(number street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city state,and ZIP code) 70/
Does applicant own property in any If yes,what county? What Taxing District? Ha ion
in Indiana? ❑Yes ❑No rvi ............ ••A person is not entitled to this deduction unless the person has a balance on the person's n '7 county
recorder's office(including any home equity line of credit that is recorded in the county yea C:11-cj t /
COUNTY AUDITOR j) ) ..,
Deduction approved in the amount of: - ' ° COO ,
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(niui tk day,year)
Fun resident address of appfi ant(number and street city,state,and ZIP code)
Person authorized by duly executed Power of Attorney or by IC 8-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street dry,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.