HomeMy WebLinkAboutMortgage_Materson ,.. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS county Township Year
"{'-=-Z FOR DEDUCTION FROM ASSESSED VAl lap ) .
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� . State Form 43709(R13/10-15)
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Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mad. NOV I 2Oi6 Form filed with
Frimg Dates.: 1) Real Property:Must be completed and dated in the calendar year for which the deduction Ls sought.
Must be filed or postmarked with the County Auditor or County ':.•. •- of; 8_71. 'where the property is EP County Auditor
located on or before January 5 of the immediately succeeding•_ :4,..r +1rm10. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real ' .. 7 -ii., S e)Qggrlfy 6Lh or of the county
where the property is located during the twelve(12) .• , ti`.. �. . .:• of each year the deduction is sought
See reverse side for additional instructions and qualifications. •
Appfoam(owrrer contract -see restrictions on+averse )
71)
T " District Key nuuriber t legal desa�tion Record number Page number
)font a 10–,O –o2 7-boa ao/ c2/5 a • oko to - 76 0
Assessed value of properly as of Mortgage/Contract un
indebtedness paid as of • Mortgage/Contra i debtedness unpaid as of Is the app&rant the sole
awrre,t dale,arrant year rozirt date,current year date of application legal or equitable owner?
aOOOG ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
•
If name on record is different than that of apprwant,Indrdte below: Is the property in question:Annum/y Assessed
Real Property ❑ A 6-1.1-7)
Nave of mortgagee or contr3sefa 0
C/J
Address of mortgagee or contrail seller number and street city,state.and ZIP code) — 1
Nameof assignee or other owns orh&der of mortgage ' \ r �(,)_s CCSS:
Address of assignee(number and steel,aTy,state,and ZIP code) J \ \ b t..c�\ "�'~ ^ a es Does qty applicant own property in any If yes,what county? - What Taxing Dist O °�' unit of deduction
in Indiana? ❑Yes ❑No orb t ,
A person is not entitled to this deduction unless the person has a balance on th \ " S[ _.....s mat is recorded in the county
recorder's office(including any home equity fine of credt that is recorded in the \ r _- me basis for the deduction.
COUNTY) _ . .
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.
nature(owner's full name) Date(month,day,yeas)
` ,cu I . lM4 — //-/9- /.,
Fug resident address of applicant(number and street,city,state,and ZIP code)
)c9Z48 w zfeo S Owc--r.,sveLLE)) 1O 47Coco5'
Person authorized by duly executed Power of Attorney or by IC 6-1.1112-0.7 Date(month,day,year)
Address of au thoriaW person (number and steel.oily,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.