HomeMy WebLinkAboutMortgage_Melton (2) A,t, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
i Presadhed by Depar mentsof Local Government Finance IL ■ lk _
INSTRUCTIONS: File Mark
To be filed in person or by mad. I��I�((�111// Form filed with:
Filing Dales: 1) Real Property:Must be completed and dated in the calendar year for which'Old Uedurgoa&l&ught.
Must be hied or posbnarked with the County Aerator or County Recorder of the county where the property is Idl County Auditor ,
located on or before January 5 of the immediately succeeding calendar year ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property.Must file ,;or o the
where the property a located during the twelve(12)months before(g y.t' I`�` ?tit yv.-'ucian sought.
See reverse side for additional instructions and qualifications. AUDITOR '
Applicant(owner w seerresaictions rse side • .
J .,K k_ c ,L
T Dct ey minter/legal Record number Page e number( —)&4
awe boo-o9i--a2S 20/3 - 3 ,ix
Assessed value of red property as of Mortgage I Contact'indebtedness unpaid as of • Mortgage I Contact indebtedness unpaid as of Is the applicant the sole
assessment date,ascent year assessment date,Oirmc date of appfimtion legal or equtable owner?
J® 007 ❑ yes ❑ No
If no,what is his/her exact sham of interest? If owned with someone other than spouse,irrdcote with whom
If name on record is different than that of applicant,indicate below: Is the property In question:AnnualyAssessed
❑ Real Property ❑ Annually Assessed
Mobile Home(1C 6-1.1-7)
Nacre of mortgagee or contract seller .{.>-0
Address of mortgagee or cono-act seder(number street cdy, 't te,and ZIP code) .
•
es
Name of assignee or other owner or holder of mortgage '
•
Address of assignee(manber and street ray,state,and ZIP code) •
Does applicant own property In any If yes,what county? What Taxing District? Has this deduction been requested If yes,slate amount of deduction in other
bindu�? ❑Yes ❑No coun years ❑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(mduddhg any home equity foe of aedt that is recorded in the county recorder's office)that is the basis for the deduction.
//� COUNTY AUDITOR •
Deduct* c42 0:)0:9
ol:
� i S tb p -I 20_____
20 20 20 - 20
5 D/a))CI-''tro �/yT� I � Date(month�°a- , . //
Caf c/j\r `• and foregoing information is true and correct and that the applicant is a resident of Indiana and
ow,. f n date application is filed.
Signatae(owii r •.• /8 _ Date(month,day,year)
�cA -ofapprKam re•and ZIP code)
IL—I S 10(irk fra0 (/ Su.; �N 54)G s/7
Person authorized by duly executed Power ofAitoney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authored person (number and street ray,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.