HomeMy WebLinkAboutMortgage_Feagley "•"a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
3-_ 1 FOR DEDUCTION FROM ASSESSED VALUATION
�' �� State Farm 43708(R131 10-15) Gibson Washington 2017
\i,,, e" Prescribed by Department of Local Government Finance _INSTRUCTIONS: File Mark
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calenda r r ich tqe•' 1 is sought.
Must be filed or postmarked with the County Auditor or Coun R �cyu ere the property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes riot assessed as Real Property:IlW..le,{vij(1((1e County Auditor of the county
where the property is located during the twelve(12)months before h'faral,q(646r year the deduction is sought.
See reverse side for additional instructions and qualifications. �'t
Applicant(owner or contract buyer-see restrictions on reverse side) actin
Brandyn Feagley cissoN
COO
Taxing District Key number/legal description N I Y AUDITOR Record number Page number
Washington 26-05-22-100-000.151-017 '.o lt' (Q.
Assessed value of realproperty as of Mortgage/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?
82,500 76;56@--lb,0 j)3 Ail Yes ❑ No
If no,what is his/her exact share of interest? 4 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
IZ) Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Top Flite Financial, Inc.
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) _
123 E Grand River Ave., Wlliamston, MI 48895 ao c c _ 0 4 t
Name of assignee or other owner or holder of mortgage n `'
s .le% 5. ecrkcv- 1 1 ca
Address of assignee(number and street,city,state,and ZIP code) R 'cc I
Does applicant own properly in ny If yes,what county? What Taxing District? n 13 O I aa3. 0 l� 1 if deduction
other county -/p
in Indiana? ❑Yes lJ+ No
A person is not entitled to this deduction unless the person has a balance on the pa....•.._ a,-�(° tin the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)trio. __.
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 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 I contract buyer of the aforementioned property on date application is filed.
Signature(owners full name) - Date(month,day,year)
Full resident address of act nt(numbe n treet,city,state,and ZIP code)
4111 N SR 65, Patoka, IN 47666
Person authorized by duty 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)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.