HomeMy WebLinkAboutMortgage_Delong STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS coo
ae FOR DEDUCTION FROM ASSESSED VALUATION ;,1
State Forth 43709(R13/10-15)
-- Presorted by Department of Local Government Finance 13 20 16
INS7RUCT7ONS:
To be filed in person or by mail. Form filed
Filing Dates 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought Auditor% !��
Must be filed orposbnarked with the County Auditor or County Recorder of the county where the properv �T�' ��er
located on or before January 5 of the immediately succeeding calendar year U I8 SON COI
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the County Auditor of the county
where the properly is located during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Ap t(ow t/aaacctt buyer-�Isee "cos on
CI T .ng Key number/legal description Record number Page number
a6 - (8Jt4- rat t -Obo„cl. co"-?0.Co ibIG, 39 $x.
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 assessrngdate,current year date of application legal or uifable owner?
ADot es ❑ 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 lute property in question:Annually Assessed
�qf-/'+)�_ea/Property ❑ Annually Assessed
Mobile Home pc 6-1.1-7)
Name of mortgagee
/I o�1r c�ontraGr __ . _
Address of mortgagee contact seller(number and street city,state,and ZIP code) —
Name of assignee or `other owner or holder of mortgage 4 ►9 7y.a s
Address of assignee(number and street city,state,and ZIP code) Drawer N O... 0-I /)12
Does applicant own property in any If yes,what county? What Taxing District? uction
dines Cfd N0 � r ,
Indiana? ❑yes ❑No . .... t ...,
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or w,,,.—..._ to county
recorder's office(including any home equity line of credit that is recalled in the county rec order's office)that is the basis for the rev,..,.......
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/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.
She mar's full ndfie) ig _ Date(month,day,year)
F ),ad/^,dress•s offaapjlcant(number and sheet,city,state,and ZIP code) p_ T /t ����
,(p (% W tC �iz G,#g K RO -'t /gf err,c 4j L q
Person authorized by duly executed Power of Attorney or by IC 6-1.1-120.7 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 S10,000.