HomeMy WebLinkAboutMortgage_Flick <to J STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
• .:a FOR DEDUCTION FROM ASSESSED VALUATION
- . '.` State Form 43709(R13/10-15)
CC.-- f Prescribed by Department of Local Government Finance F. i��'
.I 6 ,
INSTRUC77ONS: F. ri.
To be filed in person or by mail. rm sled with:
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought SEP �y6 fifi
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile I Manufactured Homes not assessed as Real Properly:Must file with the County Auditor of the coup O Recorder
era the property is located during the twelve(12)months before March 31 of each year the dedrrct�i ie sto_
See reverse A. additional instructions andquafkcations.��i COUNTY AUDITOR
App6rant(, /or contra. .. - -see ''�y"b,•�orj a'�-L'`
.1` /' /1.Q. / . 1\ /
•.� . �- I Record number Page number
/ 1/ ; •,:/d -7G -K60O.o(/3-Oo7P 4Gi .3,4//
>•value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of applca' legal or equitable owner?
/7! a:70 ❑ 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 the property in question:Annually Assessed
Real Property ❑ AnnuaflyAssessed
C Mobile Home(IC 6-1.1-7)
Name of mortgagee or contrail seller / ^
Address of mortgagee or contact seller(number and sleet,city,state,and ZIIPP/rode) (\//� C
Name of assignee or other owner or holder of mortgage
Address of assignee(number and stash city state,and ZIP code) 4 fas 0.us i/ 7 a �
•
Does applicant own property in any I If yes,what county? What Taiping District? dedu requested If y state amount of deduction
oth—' pe for
in I curreprnt y aR ❑yes ❑No
A as a balance on the person's mortgage or contract indebtedness that is recorded in the county
me D r a w C I' NO. 6r/ (/o"` t is recorded in the county recorder's office)that is the basis for the deduction.
r COUNTY AUDITOR
De
Card �t�. I I
W / 5-,. 00-6 20 20 20 20
I t
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
IPown r/contract buyer of the aforementioned property on date application is filed.
1\ Sig Cuti e(owrreYt Skit Itti /� ,I I Date(month,day,year)
FrA/es CAeseof app" t(n—umYYber QStreeteity state.and ZIP code)
Person authorized by duly executed of Attorney ly 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)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.