HomeMy WebLinkAboutMortgage_Cooper (13) STATEMENT OF MORTGAGE OR CONTRACT INDEBTETS1
I Township Year
. .` FOR DEDUCTION FROM ASSESSED VALUATION
l State Fonn 43709(R131 10-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: OCT 14 2016 File Mark
To be filed in person or by mail. Form filed with:
Filing Oates 1) Real Property.Must be completed and dated in the calendar year for which the ded�gqqq�is sought
Must be Wed or postmarked with the County Auditor or County Recorder of the ceurt1x14T�f� rs County Auditor
. located on or before January 5 of the immediately succeeding calendar year. p ctv77�I��
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with tl� /CiablMddie4blAl$TOR Courtly Recorder
where the property is located during the twehe(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions anddogyu�alifications.
Applicant(owner or ct buyer' tins verse side) 30905, ,-,^/ ^� f" n,,, 497511 jo loo
Taxing Dsbict,�7,(J!�`� (�I JCO I / 7 . "1 0C 9vc9oz- Record number Page number
Assessed value of real property as of Mortgage/Contact indebtedness unpaid as of Mortgage/Contract Indebtedness unpaid as of Is the applicant the sole
assessment data anent year assessment data,current year q date of application legal or equitable owner?
5
7 7R�j/, 7 ❑ yes ❑ No
If no,what is his 1 her exact share of interest? If owned with someone other than spume,indicate with whom
If name on record is deferent than that of applicant,indicate below. Is the property in question:Annually Assessed
p?teal Property ❑ AnnualyAssessed
• _ Mobile Home(IC 6-1.1-7)
Name of mortgagee or can ate /
Address of mortgagee or contract seller(number and sheet 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)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county �tr
in Indiana? ❑Yes ❑No currentyean ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity line of aedit that is recorded in the county recorder's office)that is the basis for the deduction.
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.
Sig re nneerrsqs fug name) , Data(month,day,yew
Full residdeent& rGss of apappfrant(number and street nit ZIP code)roil // a S /8 �l y7�/
authorized by duty executed Power of Attorney or by IC e-ti-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.