HomeMy WebLinkAboutMortgage_Pride �� . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
'° State Form 43709
Prescrthed by Department of Local Government Finance
INSTRUCTIONS: File Mark
lb be filed in person or by mail OCT 1.1 wri`" -
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought
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 ,pe(�j,Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the
where the property is located during the twelve(12)months before March 31 of each year the dertalBSeitcalMiNTY AUDITOR
See reverse a for additional instructions and qualifications.
Ap• t nor con buyer- `on reverse
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§ o � 3Ldze %3-i Jo�- ra. ?9- DOS ro/ ar7
Assessed value of real property as of Mortgage I Contract Indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,anent year assessment date,current year date of application oo legal or equitable owner?c/i 0750' ❑ Yes ❑ 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: Isthtee properly in question:Annually Assessed
9\\cal Property ❑ AnnuagtAssessed
(( Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller �� /7}277C-
Address of mortgagee or contract serer(number and street city state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code)
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Does applicant own property in any If yes,what county? Wiat Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on for
in Indiana? ❑Yes ❑No cuneni ar ❑Yes ❑No
A person is not entitled to this deduction uno«rna^_re^^^^ ^'-^'^^^--- ---tMact indebtedness that is recorded in the county
recorder's office(including any home equity li. 1T I c2 50 Cp rat is the basis for the deduction
Deduction approved in the amount of {' h o I )
Drawer NO a(f CS/
20 20 139 7 20 20
Signature of County Auditor Card NO. 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.
nan+Q Date(month,day,year)
_fFull r,eJsident address of appappliican' t(number and sweet Sy,state,and ZIP code)
\ '/C29 G,1, /ham- Scfrt&,f rraunctl$'(A) �� 417 GN
Person authorized by duly exerted Power of AWrney 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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