HomeMy WebLinkAboutMortgage_Kerns (2) a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Township Year
r -..„. FOR DEDUCTION FROM ASSESSED VALUATION
i> , " State Form 43709(R13/10-15)
•c ll Prescribed by Department of Local Government Finance
INSTRUCTIONS: NO V i 6 ZVit Mark
To be filed in person or by mall. Form filed with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought
Must be fled or postmarked with the County Auditor or County Recorder of the county where tho - County Auditor
located on or before January 5 of the immediately succeeding calendar year. I�R�GSr11v ❑ Courtly Recorder
2) Mobile/Manufactured Homes not assessed as Real Property.Must file with the County Az21t 'ortRsQbtti$Y AUDITOP
where the property is located during the hvelve(12)months before Mardi 31 of each year the deduct on is sought. - - -
See reverse side for additional irsWctions and qualifications.
Applicant(oonn9r or contract -sae res tri/"Wons on`reverse ssiid/e) -
TaWlistrict Key number/legal desalpiim Record number Page number
i/ 7 god =lo// -957a
Assessed value pmpeny as of Mortgage/Contract indebtedness unpaid as of - Mortgage/Contact indebtedness unpaid as of Is the appeased the sole
assessment dart,anent year n®d date,amend year date of application legal or equitable owner?
.,24—V 7-110—/O0tZOJ O—O J ❑ 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:Annn unnually Assessed
' peal Properly ❑ Mobile ay 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contact seller(number and street dry state,and ZIP code)
.
Name of assignee or other owner or holder of mortgage '
•
Address of assignee(number and street ray,state,and ZIP code) •
Does applicant own property in any If yes•what county? - What Taxing District'? lies this dada:on been requested If yes,state amount of deduction
other in dam? ❑Yes ❑No - current year? ❑Yes ❑No
A person is not entllled 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(including any home equity fine of aedt that is recorded hi the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR • • -
Deducbon approved in the amount of
20 20 20 20 20 20 20
Signature of CountyAudtn 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 I contrail buyer of the aforementioned property on date application is filed.
Synafara(own to g:: I Date(month,day year)
Fun resaddress of �` (nom end sheet city,state,and�(P code)
993 Li /000 W r( nhaa tiedtM 3/7b‘s
Person authorized by duly executed Power of Attorney or by IC 6x1.1-12-0.7 Date(month,day.year)
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 510,000.