HomeMy WebLinkAboutMortgage_Roberts (10) a, STATEMENT STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS county Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
Plats Fore 43709 Department part 10-15)nt of T'1�
Prescribed by Departrnent of local Government Finance ���a}}M—��ttii���J�.�g�-�.
INSTRUCTIONS: -Mid
To be filed in person or by mall. F
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought NOV _ Q��`u lu
Must be filed orposbnadred with the County Auditor or County Recorder of the county where the property is LJ minty Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property.Must file with the County Auditor of the Recorder
where the property is located during the twelve(12)months before March 31 of each year the deduction is sotgnrt.W' -
See reverse side for additional instructions and qualifications.
Appleant(owner or restrl on ve .
T number
OIBSO NNN COUNTY AUD
Record number Pact_
3 ac legal
. 1
Assessed value dreai pmpeny as of Mortgage/Contract indebtedness unpaid as of - Mortgage I Contract indebtedness unpaid as of Is the app&rant the sole
assessment date,=Tam year asssmta d dam,and year
Uon legal or equdable owner?
d 01 ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with-someone other than spouse,indicate with whom •
If name on record is different than that of applicant,indicate below. Is the property in question:Annually Assessed
• Oiled Property ❑ Annually Assessed
/� •^ Mobie Home(IC 6-1.1-7)
Norte d mortgagee a contract seder E 1 A u
Address of mortgagee or contract seller(number and street,city,state,and ZIPI/code)
•
Name of assignee or other owner or holder of mortgage '
•
Address of assignee(number and sheet,ahy,state,and ZIP code) •
•
Does applicant mart property in any If yes,what county? - What Taxing District? Has this deduction been requested I yes,slate amount of deduction
other county in Indiana? ❑ current Yes ❑No - cent year? ❑Yes El No
A person is not enblfed to this deduction unless the person has a balance on the person's mortgage or contact indebtedness that is recorded in the county
recorder's office(including 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 Canty Date(month,dal:year)
I t 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/=tract buyer of the aforementioned p petty on date application is Tied.
I hAl n.. .-) / ' Date(month,day,year)
, / -49--k0
FtA: h and\- city, t or,a Q t i{I P coda) �W ' 1 `qtr l -l. ) C 7 o
Person authorized by duly executed Power ofAttorney or by IC 6-1.1-1r�2-0..77 `y--_ Date(month,day.year)
Address of authorized person (number and sheet,cgs state,and ZIP oode)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.