HomeMy WebLinkAboutMortgage_Schmitt (3) s STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
frf FOR DEDUCTION FROM ASSESSED VALUATION
t. - State Form 43709(R13110-15) i A
Prescribed by Department of Local Government Finance F II ,E t,: .
INSTRUCTIONS: File Mark
To be filed in person or by mail. DEC 2 8 20,1t6 Form fled with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is soug
Must be filed or postmarked with the County Auditor or County Recorder of the con ty where the property is like unty Auditor
located on or before January 5 of the immediately succeeding calendar year. • ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the le county
where the property is located during the twelve(12)months before Mandl alaratittliteeegferpagopmffht.
See reverse side •-):•ditiona/instructions and qualifications.
Applicant(owner��„- - rest / revs )ckn-rui*
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t•� /, ; ( / Key I legal description Record number Page number
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Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment dath,aurent year assessment date,colt year date of application legal or equitable owner?
05000 ❑ Yes ❑ No
If no,what is his/her exact share of interest? If armed 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:Annually Assessed
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgag e
Address of mortgagee or contact seller(number an street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on pro for
in Indiana? ❑Yes ❑No Curren yeah ❑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 equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
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Deduction approved in the amoun . Gr a4 ScI-nr)r1 T'i-• `. ..
20 20 20 20 20
Drawer NO 07012-9-5Ltso C ,
Slgnatu aunty 'nor • {. Date(month ye
a / - 8-
01 /
IF We certify under the per,__ Card
�1 O. ;true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is flied.
Signahu ( namm i -, Date(month,day,year)
41—ull resident address of applicant(number and sheet city state,and ZIP code)
70. 5 L;ncoir, Si-- F'L 1.3cn,ich ,T'O, '17v8
erson 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$10,000.