HomeMy WebLinkAboutMortgage_Bennett (3) STATEMENT OF MORTGAGE OR CONTRACT INDEFE a r SS�
FOR DEDUCTION FROM ASSESSED VALUATION { 'i' 1+ Township Year
State Faun 43709(R13/10-15)
I
Prescribed by Department of Local Government Finance •
INSTRUCTIONS:
NOV 3 0 2016 File Mark
To be filed in person or by mail. - Form fled with:
Elting Dates: 1) Real Property:Must be completed and dated in the calendar year for which the dyU)o
Must be Red or postmarked with the County Auditor or County Recorder of th property is ounty Auditor ,
located on or before January 5of the immediately succeeding calenddMSS ON COUNTY AUDITOR
2) Mobile I Manufactured Homes not assessed as Real Property.Must Re with the County Auditor of the county County Recorder
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought.
See reverse side for additional instructions and qualifications.
Apprvant(owner srorwad sce4-,-.;,;ac reverse side) •
slij W7
ra' 2 I Record
-,3ol As/ . I -0 a 8 • number o
Assessed value areal properly as of Mortgage/Contract indebtedness unpaid as of • Mortgage I Contract indebtedness unpaid as of is the applicant the sole
assessment date,current year amassment date,anent year date of apprcalion legal or equitable owner?
Coot& ❑ Yes ❑ No
tf 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::!Annnauaalllly Assessed Assessed
Property ❑
Mobile Home(IC 6-11-7)
Name of mortgagee or contact seller
Address of mortgagee ct setter(number street city,stale,and ZIP coda)
6 N
fi
Name of assignee or other owner or holder of mortgage ' .'I
Address of assignee(number and sliest,thy shoe,and ZIP code) • h�n $�N� I.
•
Does applicant owe property in any If yes,what county? • What ��}J ' t /" es,slate amount of deduction
other ❑No
in India county ❑Yes
A person is not entitled to this deduction unless the person has a ba/a ( � 'at is recorded in the county
recorder's office(including arty home equity fine ofrre&that is mcon. I . _,a deduction.
C. -
Deduction approved in the amount of - - -.
20 20 20 20 20 20 20
Signature of County Attract County Date(north,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and coned and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signah/e}owner's MI name) Data(morrth,day,year)
/era der Aw ttyro��
Full resident address d app- (number and sire ray,state,and ZIP code)
X / /! S-. /SRotlhirie&J GtQ. p1;_
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet oty,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.