HomeMy WebLinkAboutMortgage_Clark (3) � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
- Court Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
---" State Fin 43709(R13/10.15) � �
Prescribed by Department of Local Government Finance �. �:
PISTRUCTIONS: dt M- ' �.'
To be filed in person or by mall Form tied with
Faing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. 9'nn
Ofl
Must be filed or postmarked with the CountyAuddor or County Recorder of the county where the property is DE( id Il 'Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ • ■ - set
2) Mobile/Manufactured Homes not assessed as Real Property.Must file with the CzvmtyAuditor of the county
where the property is located during the twelve(12)months before March 31 of each _-n
nrg ( ) year .�� -is
See reverse side for additional instructions and qualifications.
Appikant tomera -see on reverse side) .- CIBS9u Cf lINTY AUDITOR
Taxing District Key /legal° Record Page number
osa—loo — D03. (a�5-Dl'] 5-04�
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of • Mortgage/Contract indebtedness unpaid as of Is the appfxant the sole
assessment date,aarent year assess date of application legal or equitable owner?
If no, indicate with whom
,what is his I her exact share of interest? 'Ol( I If owned with someone other than ❑ Yes ❑ No
If rare on record is different than that of applicant,indicate below: I Is n t hRe epm ro pPerroty o In tqy u❑ Annually
A Assessed
AJlHm
(IC 61.1-7)
Name of mortgagee or contract seller �
Address ofrtangagee or contrail seller(number and street:city,state,and ZIP cc Drawer, NO c""/()
Name of assignee or other owner or holder of mortgage ' Q
Card NO. ( �o /�
ray,
Address of assignee(number and street, state,and VPcode) J ∎ L a—(/(
Does applicant own popery N any If yes,what county? • What Taxing District? Has the deduction been requested if yes,state amount of deduction
other county in �? ❑Yes ❑No - amem ❑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(including any home cowry fine of audit 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 CowdyArrrfdor County Date(month,day,year)
I 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/.. d buye e ato • entioned property on data application is filed.
Sgnahae( `'� / Date(month,day,fear)
F 1 eat a.. .. ofo/f'avert(numberand street,city;staynd P )
2-1 aso N sR (,s a � 4 -kW .
Person authorized by duly executed Power afAttrrney or by IC 6-1.1-120.7 Date(month,day,year)
Address of authorized person (number and street 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.