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HomeMy WebLinkAboutMortgage_West STATEMENT OF MORTGAGE OR CONTRACT INDEBTED SS Court Township Year `f' ,±: FOR DEDUCTION FROM ASSESSED VALUATION I G ,? ` State Forth 43709(R131 10-15) % ✓ Prescn'bed by Department of Local Government Finance INSTRUCTIONS: OCT 2 6.2016 File Mark To be filed in person or by mail. Form filed with; Filing Dates 1) Real Properly.Mud be completed and dated in the calendar year for which the deduction• sought ,._/ Must be filed orposimarked with the County Auditor or County Recorder of the county y� : the f;, .- r,' ( County Auditor located on or before January 5 of the immediately succeeding calendar year. (ja ' '4471,1r LED 2) Mobile/Manufactured Homes not assessed as Real Property:Must file with thb'z. County Recorder where the properly is located during the twelve(12)months before March 31 of each �f redrxtionn MPR See reverse side for dditional instructions and qualifications. Applicant(owner or ct buyer-see use / 1/1 I. (� i ' • /KJ�l�N7 . • Key number/ '. Record r Page number c� 34 Soo-o o•ca5-� ors ai98 vas of real property as of h Mortgage I Contract indebtedness unpaid as of Mortgage 1 Contract indebtedness unpaid as of Is the applicant the sole assessmem ctlrrerd year assessmem�ate�purrent� date of application legal or equitable owner? �—�(C��7\\ll ❑ Yes ❑ No If no,what is his I her exact share of interest? I If owned with someone other than Name,indurate with whom If name on record is different than that of applicant indicate below. Is the property in question Annually Assessed ❑ Real Property ❑ AnnuallyAssessed ( / �1 Mobae Home(IC 6-1.1-7) Name of mortgagee or contract seller �, I _ /� P d \ �'� 1 / ri Address of mortgagee or contract seller(number and street city,state,and ZIP r, 8 \y\/\ F•�y)(,•'l)7„N/(/„r Name of assignee or other owner or holder of mortgage Address of assignee(number and street illy,state,and ZIP code) ,. Qn fYnTh Does applicant awn property in any If yPS/—•" -n lY'"" axing District? Has this deduction been requested If yes,state amount of deduction in Ind cal? ❑Yes P! p/�� 1 1�� J on property ❑Yes ❑No A person is not Y QOM_ tp� nce on the person's mortgage or contract indebtedness that is recorded in the county recorder”-- 4 �t� !�©,5',.••' 9c, dUNTY county recorder's office)that is the basis for the deduction. Deduction. ,C`�CC \' 20_ `''• • 20 20 20 20 C�1 c1� S.• ., .ICo O County Date(month,day.year) /We certify under the penalty of perjury that the a6die ind 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 (owner's h l name /�_/ Date(month,day,year) � ��. u� address of applicant(number and sleet ally,state,and ZIP code) Z1 33 5 Flo W 4cLubs 4 , TAJ 4{1 (x39 Person authorized by duly executed Power of Attorney or by IC 8-1.1-12-0.7 Date(month,day,yeas) Address of authorized person (number and sheet 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. •