HomeMy WebLinkAboutMortgage_Haas (2) e• STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
s. FOR DEDUCTION FROM ASSESSED VALUATION Sfnta Form 43709(R13/
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Prescribed by Department 5of Local Government Finance /
INSTRUCTIONS: File Mark
To be hied in person or by mad. DEC 2 F4'7..with:
Fang Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the properly'. ❑ r. .• Auditor
located on or before January 5 of the immediately succeeding calendar year. - • lr_-ei
2) Mobile f Manufactured Homes not assessed as Real Property.Must file with the County Auditor of the co. , �� m/� ^tY Recorder
w the e property is located during the twelve(12)months before March 31 of each year the decht.,: •e,•, •t'm U ' • '
See reverse side for additional instructions and qualifications. ,lCf /� /\ `
Applicant V ) „' El /V.
Taxing District Ke number/legal Record number Page number
. Key cis-4 — , s oo364;-oi7 1 • 3({ ? v
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of • Mortgage r Contract indebtedness unpaid as of Is the app5card the sole
assessment date,arrant year =rent year date of application legal or equitable owner?
� �(,.! ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than sire te.a,indicate with whom
If name on record is different than that of applicant indicate below: Is the property in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller E ..mot
Address of mortgagee or contract seller(number and sheet city,state,and ZIP code)
Name of assignee or other owner or holder of motgag-
°2° it, — 3 171 70
Address of assignee(number and street city,state,at
Does applicant own pope]ty in any If yes.what coo
Drawer �O been requested If � •
yes,state artnoum. deduction
in Indiana? ❑Yes ID No )Yes 0 N
A person is not entitled to this deduction unless I Card N O. ntract indebtedness that is recorded in the county
recorder's office(ncludmg any home equity fine Sat is the basis for the deduction.
CUUNI7 AUlnl con
Deduction approved in the amount of:
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20 20 20 20 20 20 20
Signature of CortyAudito .County Date(month,day,year)
I f We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
own r!contract buyer of the aforementioned property on date application is filed.
- ,fbwan s hAname)alnt j' a�(d�I (� �1 Date(mod.day,year)
r r6- l b �(\I VI�I (}n6-5 o L state, 1 P ) v�✓1 (-b 1040 CIO
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12.0.7 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 510,000.