HomeMy WebLinkAboutMortgage_Johnson (36) `,r,' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS n'�TDwr> Year
FOR DEDUCTION FROM ASSESSED VALUATION i9Eh -i'
State Forth 43769(R13/1415) - 5 I
Prescribed by Department of Local Government Finance
INSTRUCTIONS: NOV 2 &IMO rk
To be filed in person or by mad Form Med with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought.
Must be hied or postmarked with the County Auditor or County Recorder of the county where the pm.7i.r,. .%TAJ!( County Auditor ,
located on or before January 5 of the immediately succeeding calendar year. (;I B)SN C QLl NTY •m mow Retarder
2) Mobile/Manufactured Homes not assessed as Real property.Must file with the CountyAudrTor o county
where the property is boated during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant vner or contract buyer-see tri ' on reverse side)
T District Kev m I n l nxnmiim Record number Page
r ac;-I DO- 3b1 -ODD Zit-oag do/ 6 4
Assessed value of mat xoperffi as of Mortgage t Contract indebtedness unpaid as w • Mau Aamw.
assessment data,current year I assessment date.arrterrt year I date d appfimban legal a equitable owner?
6' 01 ° . El Yes 0 N
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 appb:ant,indicate belay. Is the property in question:Annually Assessed
❑ Real Rupcsty ❑ Annually Assessed
Mob&Home(IC 61.1-7)
Nam of rnon9ag�i� )
•
Address of mortgagee or contract seller(nwnber and street,city,state,anandvC'ZII PP-^cod-e)
Name of assignee or other owner or holder of mortgage '
•
Address of assignee(number and street city,state,and ZIP code) .
Does applicant own property In any If yes.what county? - What Taxing District? Has this deduction been requested If yes,slate amount of deduction
iindiar a? ❑Yes ❑No cement 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(mdudmg any home squiffy fine ofcredrt that is recorded in the county recorder's office)Mat is the basis for the deduction.
COUNTY AUDITOR - - -
Deduction approved in the amount of
20 I - 20— _i-- _. —I _ 20 - 20 20
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Signature of County Auditor �,^(/(�' Date(month,day,year) - -•
I/We certify under the pen
Drawer U 11 I 1i O''`"••'•u ••.., s true and coned and that the applicant is a resident of Indiana and
owner/contract buyer of th
X�/ Signature( name) Card NO. Date(month,day,year)
r� t.
Full resident address of applicant
(1310 A too Y 14, 10
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0. 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$10,000.