HomeMy WebLinkAboutMortgage_Perry (8) >< STATEMENT OF MORTGAGE OR CONTRA _ TE County Township Year
f — FOR DEDUCTION FROM ASSESSED VALUAOIY�
A= State Form 43709(R13110.15)
�- Presalbed by Department of Local Government Finance OCT 19 2016
INSTRUCTIONS: File Mark
To be filed in person or by mail Form filed with:
Ring Dates f) Real Property.Must be completed and dated in the calendar year for .4 r is so ht
Must be filed orposhnarked with the County Auditor or County --.. .r- ':f _ sil,P.111;11‘AtintiaRrOperly is County Auditor
located on or before January 5 of the immediately succeeding r 9A -
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the CountyAuditor 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.
Applicant(owner or contract buyer buy�er�-7see on reverse side)
Y/) r ltAalD W Page number
Taxn ist Key number/ description Record number
(iva�ea aiti a G ,a - - yo 3 0o-91 .J/7U c2-ic- dOi/o °<i,
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment data,cturent year date of application legal or equitable owner?
/0725 7 El Yes No
If no,what is his/her exact share of interest? If owned with someone other than spouse,intricate with whom
•
If name on record is different than that of applicant indicate below. _ I.)q roperty in question:Annually Assessed
jq-goal Property Il AnnualyAssessed
•
5\3 (IC a 1.1-7)
Name of mortgagee or contract seller 15/ E'I Ulf 0757 cj
Address of mortgagee or contract seller(number and street city,state,and ZIP code) CPO I f
4
D 1'a 11'el- NO
Name of assignee or other owner or holder of mortgage
Card NO. C
Address of assignee(number and sheet,dty,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 p for
in Indiana? ❑Yes ❑No aarenf yin ❑Yes ❑No
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 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.
Signature(ayy is foil n Nl Date(month,day,year)
Full resident address of applicant(number and street cry,state,and ZIP code)
N 0214 6- � , �, ho 1/76,70
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.