HomeMy WebLinkAboutMortgage_Cox (12) � STATEMENT OF MORTGAGE OR CONTRACT INDEBT
� Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
t.e. r` State Fan 43709(R13110-15)
S': -f Prescribed by Department of Local Government Finance
INSTRUCTIONS: DEC 19 2016 File Mark
To be filed in person or by mail. Fenn Bled with:
Rfrng Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought.
Must be tiled or postmarked with the County Auditor or County Recorder of the� ID-aunty Auditor
located on or before January 5 of the immediately succeeding calendar r ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property.Must file @NIAI v_�
where the property s located during the twelve(12)months before Mardi 31 fe each�the deduction Is sought
See reverse side for additional instructions and qualifications. •
resypons Bonn le �r �a-I2)
Applicant(owners (7 I\ C/ lk A A OR Ce
T ct Key number I legal desaiption Page ge r
l�tn�cca 9.c0— I3-a 3 -lot-CO I . 073-00c,073-00c, O o-3
Assessed value of real property as of Mortgage/Contact indebtedness unpaid as of - Mortgage/Contract"indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment dam,and year rate of application legal or equitable owner?
Sr /09000 ❑ Yes ❑ No
If no.what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom •
If name on remitd is different than that of applicant indicate below. Is the property in question:Annually Assessed
❑ Real Property ❑ Ndttr�yAssessed
Name of mortgagee or contract setar '' II Houle(�61.1-7)•
Address of mortgagee or contract seller(number and sheet city,state,and:•code) UUUU
Name of assignee or other owner or holder of mortgage ' .
Address of assignee(number and street,r8y,state.and ZIP code) .
Does applicant own property in any If yes.what county? What Taxing District? Has this deduction been requested If yes,slam amount of deduction an PrOPedY for
Indiana?other county in ❑Yes 0 N • current year? ❑Yes 0 N
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 eglaiy line ofesedit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR ' -
Deducton approved to the amount.t.-
•
20_ 3C/02 .• 20 20 20 20
Drawer NO .
Signature of C
County Date(month,day,year) -
•
I/We cent Card NO. 3 3 dog information is true and coned and that the applicant is a resident of Indiana and
owner/co !I �x 'cations bled.
Signature lawn 02-9'1 C3 Date(moth,day year)
)21 resident address of applicant(number and street dry,state,and ZIP code)
Jo 19t4a 5, Dhas�`rtn�. I-14s 2.d. CzaUcAcl (' Illy ,TA). Liis1 C0
Person authorized by duly eremmt Power ofdtorney or by IC 6r1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,ley,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.