HomeMy WebLinkAboutMortgage_Dick (2) STATEMENT OF MORTGAGE OR CONT
' n
EB County y Townshi P
Year
� s FOR DEDUCTION FROM ASSESSED VAL n k
�. State Form 43709(R13110.15)
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Prescribed by Department of Local Government Finance
rNSTRUCnons: SEP 2� 7.61 File Mark
To be filed in person or by mat i .i Form filed with:
Filing Dates 1) Rea Property Must be completed and dated in the calendar year for Si•ns -_v['' 4r}`i►-: ::'. t
Must be filed or postmarked with the County Auditor or County -:•• -,. re the property is unty Auditor
located on or before January 5 of the immediately suoceeding'•�•+ ,l'.!•. County Recorder
2) Mobile/Manufactured Homes not assessed as Real Rope • !l!e with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of oath year the deduction is sought -- -
See reverse side for additional instructions and qualifications.
App(can;( ,con buye kee ns on reverse side)
K!�N}rJt ///)Key number/legal description Record number ' Page number
cater 26-ia-07- yo/ oe)a .S93-0 Ez aoi& 'Icy.3
Assessed value of real property 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 ear date of application legal or equitable owner?
57750 ❑ Yes El 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 applicant,indicate below. Is the property in question:Annually Assessed
9Esal Property ❑ Annually Assessed
7 Mobile Home(IC 6-1.1-7)
Name of mortgagee or Tact seller
Q8
Address of mortgagee or con eger(number and street dry,state.. -- -
Name of assignee or other owner or holder of mortgage — �/�/1 �I C F/—�{N 1 2--...
Address of assignee(number and street dry,state,and ZIP code) j 6 t _. �J-J 7' --
Does applicant own properly in any if yes,what county? ( / lJ (eduction
other a county - 511 750
o Indiana? ❑Yes ❑No
A person is not entitled to this deduction unless the person 1 the county
recorder's office(ulduding any home equity line of credit the
Deduction approved in the amount ot. I (0.
_ / (i 3
20 20 20 J hIJ li 0
Signature of County Auditor
I/We certify under the penalty of perjury that the above an liana and
owner!contract buyer of the aforementioned property on d
Sig - ; u;;i- 5rH names) Date(month,day,Yeah
Full r- /1,�. AlVdltll�P~\/hcanl t(number s��tt city,state,and code)
5° a10 Se 2J4rrarL 7'/Trinst, X7670 .
Person authorized by duly executed Power of Attorney or by IC 6-11-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
The penalties for per)ury can include imprisonment up to two and a half years and a fine not to exceed$10,000.