HomeMy WebLinkAboutMortgage_Beasley s . STATEMENT OF MORTGAGE OR CONTRACT INDITIISr '•iv Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
G'' State Fonn 43709(R13/10-15)
'
Presorted by Department of Local Government Finance
OCT 19 2016 File Mark
INSTRUCTIONS:
lb be filed in person or by mail Form filed with:
Filing Dates 1) Real Property Must be completed and dated Audder or calendar year which•gt:.••'..'t'--. •
Must be filed or postmarked with the Co a property is County Auditor
located on or before January 5 of the immediately succeeding cafe r 6)N CO NTY AUDITOR
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county County Recorder
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought.
See reverse side for additional instructions and qualifications.
Ap t(owner or contract buyer sips re side)
Taxing D 4,-/\Key number/legal tle `
Record number Page number
¢ olio i -A5 0200 063 9o9 �a RO/7o 5'028 7
Assessed value of reat property as of Mortgage/Contact indebtedness unpaid as of Mortgage I tract Indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessmr date,current Y r date of application legal or equitable owner?
(oS� o • ❑ Yes ❑ No
If no,what is his I her exact sham of interest? If owned with someone other than spruse,indicate with whom
If name on record is different than that of applicant,indicate below. s the property in question:Annually Assessed
Meal Property 0 Annually Assessed
•
• Mobile Home(IC 6-1.1-7)
Name of mortgagee('cogritracrei
Address of mortgagee or contract setter(number and street city,state.and ZIP code) ._ 4
Name of assignee or other owner or holder of mortgage 0� Y tO\CSI )t"�(a c.n..k
rJC�\S' �I O
Address of assignee(number and street city,state,and ZIP code) l`�i�y�` 0201 L. _ U C
. l o
Does applicant own property in any If yes,what county? What Taxing District? 7r S- 0 10 O 0. O U c-1 limn
other in Indiana? ❑yes 0 N Iarreniyear? LJ Yes unu 1 -a�-1�
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 credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount at
20 20 20 20 20 20 20
Signature of County Auditor County Date(month,day,yea)
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!contract buyer of the aforementioned property on date application is filed.
S natu ) r Date(month,day,year)
Fug r (�/d dress of umbu an cdy,��,and LP Code)
‘7° 76/ 9 Varh 4. id oc.ohm , 'f 767 0
Person authorized by duly executed Power of Attorney or by IC 6-1A-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.