HomeMy WebLinkAboutMortgage_Breitweiser STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
t' FOR DEDUCTION FROM ASSESSED VALUATION
.` State Form 43709(R13/10-15)
Prescribed by Department of Local Government Finance i
INSTRUCTIONS: " i - ) ark
To be hied in person or by marl. - - i
,. tad with:
Filing Dales: 1) Real Property:Must be completed and dated In the calendar year for which the deduction is sought
Must be filed or postmarked with the Gourd),Auditor or County Recorder of the county wharf PtenMrs
LL UU 16 ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Properly.Must file with the County Auld' of�h ❑ Cvunb Recorder
where the property is located during the twelve(12)months before Mardi 31 of each year the uction' so -
See reverse side for additiona l instructions and qualifications. CIDSOfy COUNTY •
(ovmeror ctbuyer.-see restrictions on reverse side) • . a AUDITOR
in , "
T frict h Key number/legal description Record number Page number
a62 —/V- ao - SOO — 000 . 78/ -oo4 aof‘:. 3959
Assessed value olrard properly as of Mortgage/Contract indebtedness unpaid as of . Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment data.currant year assess end date,arrant year date of application legal or equbable owner?
'CildeZ d 0 40 ❑ yes ❑ No
If no,what is his!her exact share of interest? t owned with someone other than° .P,indurate with whom
If name on record is different than that of applicant,indicate below Is the property In question:Annually Assessed
- -- 1❑_RealPrwccty fl Annually Assessed
1.1-7)
Haire of mortgagee or Contact seller S 3
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) C2d Co
Drawer NO
Name of assignee or other owner or holder of mortgage . q j
Address of assignee(nurwer and street.aiy,state,and ZIP code) • Card NO. r� /� ` —,
J°T S&) a o.4 8 - ;4- L .
Does applicant own property in any If yes,what county? . What Taxing District? Has this deduction been requesteC u 7=....__..__._. n
other county in Indiana? ❑Yes ❑No arrant year?�` ❑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(indudmg any home equity fine 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!contract buyer of the aforementioned property on date application is filed.
.,,- (owner's ) - Date(month,day,year)
. I
�F is 49i E )OO aKla e(P�l,)I d,/ L
N y7� t� ()
Person authorized by duly executed Power of Atrnhey or by IC 61.1-12-0.7 / � Date(month,day,year)
Address of authorized person (number and street,aIy,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.