HomeMy WebLinkAboutMortgage_Davis STATEMENT OF MORTGAGE OR CONTRACT INDEBT E
its:_-- `;1�••) ty Township Year
FOR DEDUCTION FROM ASSESSED VALUATION'! ?-
1'• State Form 43709(R13/10-15) �7
c Prescribed by Department of Local Government Finance
INSTRUCTIONS: SE? 2 9 2016 File Mark
lb be filed in person or by mall. Form filed with:
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the •.,. ,.:. i:,,_,---11 t
Must be filed orpostmadced with the County Auditor or County Recorder of the,0!,t; r,* fir:e•�= .y. County Auditor
located on or before January 5 of the immediately succeeding calendar year. tpit`' ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file�f"q{�S1*11:011,Audrtor of the county ,
where the property is located diving the twelve(12)months before Mardi 1 of f each year the deduction is sought
See reverse side for additional instructions and qualifications.
Appfur or contact buyer- Zys on rave ) •
T. • D'. / Key number 1 Record number a number
i.i,.��1) a /0- 8- 010- Jco az? 3"�j6 -oaf NO/b Page number
of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
• -nt date,current year assessment date,current par date of application legal or equitable owner?
/8.(7(100d ❑ 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
0 Real Property ❑ AnnuallyAssessed
Mobile Bone(IC 6-1.1-7)
Name of mortgag contract seller
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other other or holder of mortgage ----- _
Address of assignee(number and street city,state,and ZIP code) 11� .,
Does applicant own property in any If yes,what county? What Taxing District? U I a)t•C'1• I\r0..,,(2)/69
other county •.
on
In Indiana? ❑Yes ❑No '
A person is not entitled to this deduction unless the person has a balance on the person Ca rd N o .. "aunty
recorder's office(inducting any home equity line of credit that is recorded in the county i ••• •• (. I
COUNTY AUDITOR F
Deduction approved in the amount of
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 I contract buyer of the aforementioned property on date application is filed.
Sig c .„ t, .1�- V f(Lu t.I l Date(month.day,year)
p �� / Gl_/tl
-. Aaddress of applicant(number and street city,state,and LP code)
104-19 (S. Rhtasant "Kk. ) 4-1119
n,
Person authorized by duly 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.
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