HomeMy WebLinkAboutMortgage_Matsel (4) STATEMENT OF MORTGAGE OR CONTRACT INDEB NESS
Coin Township Year
�"-� FOR DEDUCTION FROM ASSESSED VALUATION
h= Slate Farm 437�(R13/ials) 'L
Prescribed by Department of Local Government Finance
INSTRUCTIONS: DEC 1.2 2016
. File Mark
To be filed in person or by mad. Fomn feed whir:
Filing Dates: 1) Real Properly:Must be completed and dated in the calendar year for which the d-. .'.n is sought.
Must be filed or postmarked with the Counly Auditor of County Recorder of the -;- , is County Auditor ,
located on or before January 5 of the immediately succeeding calends i, •S'I J •• ❑ County Recorder
2) Mobile/Manufac8aed Homes not assessed as Real Property.Must file I.- ..
where the property is located during the twelve(12)months before March 31 of each year the .•.,..s tfddught.
See reverse side for additional instructions and qualifications.
Applicant(owner...:!�!. ,.buyer-see side) /
gTM.AW .. l�� a.a& __ p
Assessed value of real property as of Mrtgage/Contract Indebtedness unpaid as of - Mortgage I Contract indebtedness unpaid as of Ls the applicant the sole
assessment dots,current year ue,erd date,arrant year date of am:amtion legal or equtable owner?
❑ Yes ❑ No
If no,what is his F her exact share of interest? If owned with someone other ban spouse,indicate with wham •
If name on record is different than that of applicant,indicate below- Is the property N question:AnnualyAssessed
❑ Real Property ❑ Annually Assessed
Mobile(Home(IC 61.1-7)
Name of mortgagee or contact seller - A4 _
Address of mortgagee or mrtract setter(number and street , c_ ;'1\S
- doss.-\
Name of assignee or other owner or holder of mortgage ' V la q,\I ' t
Address d assignee(number and sheeta7y state,and BP 4 a S / tit ��� - -
Dog appfrant awn property in any If yes,what county? ,� T b iJ O • \a–Ka^ requested t yes,state emou t of deduction
other in Indiana? ❑Yes El No I 1a__ ures ❑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
recorders office(including any home equdy fine of credit that is recorded in the county recorders office)that is the basis for the deduction.
COUNTY AUDITOR • .-
Deduction approved in the amount of
20 20 20 20 20 20 20
•
n .r / 'County , Date(month,day,year)
=1 _
I/We certify under the penalty of perjury that the -''.7 W rrregoing 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 fled.
Sigrabrre( e/s fiID na�me7
Data(month,day,year)
Full resident address of applicant(number and sheet,thy,state,and ZIP cede)
a0-2 AL SecolsD 5fret awrvsJ.'l/e/IA/ .1r76665
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 ay,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.