HomeMy WebLinkAboutMortgage_Conway (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(813110.15) `•
Presaibed by Department of Local Government Finance
INSTRUCTIONS:
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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 soug)0,OV 1 7 701 I'
Must be filed orposbnadmd with the County Auditor or County Recorder of the county where the property is j County Auditor ,
located on or before January 5 of the immediately succeeding calendar year. G County Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly.Must file with the County Auditor of t ' it d
where the properly is located during the twelve(12)months before March 31 of each •;,:'':::1 Mo��J h.
See reverse side for additional instructions and qualifications. year the died
q vl$SON COUP. AUDITOR
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Taxing 0(V/strict Key number/legal description Record number Page number
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assesmrerd date,currant year assessment dab,=rent year date of application legal or equitable owner?
/ -D 00 v D Yes ❑ No
If no,what is his I her exact share of interest? If awned with someone other than spouse,indicate with whom
If name on record is different than that of app&ant,indicate below. Is the property In question:Annually Assessed
pSbal ihopety 0 Mobile Home 6(IC 1.1-7)
Nate of mortgaggep ar contract seller )
Address of mortgagee or contract seller(number and street city,stab,and ZIP code) a° (c` l --!__
Nacre of assignee or o t h e r or holder of mortgage ' Q;rcc J . d \C c.
Address of assignee(number and street city,state,and ZIP code) • C0%\t I %v + , \ ,0.._, —
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Dees t own property in any If yes,what puny? . what Tadrg Debict? on property 13 ,loo I(-.
in Indiana? DYes ❑No anent yeaR u rci - _1" _
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recordeo In um
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
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Signature of CoumyAuddrr 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 leaident of Indiana and
owner/contract buyer of the aforementioned property on date application is fled.
Sr name) 9 Date(month,day.year)
Full resident address of applicant(number and eget city,state: ZIP
code)
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Person authorized by duty executed Power ofAttwney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,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. ___