HomeMy WebLinkAboutMortgage_Asay (2) P0 STATEMENT OF MORTGAGE OR CONTRACT INDEBTtDNt Cou Township Year
It 4- FOR DEDUCTION FROM ASSESSED VALUATION
'.^ State Form 43709(873110.15) SE.? 3 2��
Presabed by Department of Local Government Finance
INSTRUCTIONS: 4gRj�� OR lie Mark
To be filed in person or by mail. folUt4 AVDIT Form filed with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which tl(s rrss sought �pp
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is /n County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county ❑ County Recorder
whem 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.
App6rmy(pwneracon G l reveise side) C `J- ^
Taxing Dsfi legal Key number/ al description Record number Page number
Q6-013 oz- ti a3 CZ" 7/3 - i ao/ a `131 7
Assessed value of real property as of Mortgage/Contact indebtedness unpaid as of Mortgage/Contract Indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,curve year date of application legal or equitable owner?
c OCC) ❑ yes 0 N
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
AZ
Real Property ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contact seller 7 F '
Address of mortgagee or contact seller(number and street city,state,and ZIP code) -9" - —
�a' ct cJ S. -4
Name of assignee or other owner or holder of mortgage CT FC_k
Drawer NO
Address of assignee(number and street city,state,and ZIP code)
-C1�-`i3cco . t:110(50.00
Does applicant own property in any If yes,what county? What Taxing District? Card NO. y-L7.. udion
in Indiana? ❑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 mooned 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)
11 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 bled.
SSiignatr owner's lull name) ) Date(ur Ruh,day,year)
Full�a resident address d-app t( street,city, te,and ZIPcode))/ ,1 - it '!
Person authorized by duty executed Power of t r by IC 6-1-1-12-0.7 r Date(month,day,year)
Address of authorized person (number and street city,state,and LP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.