HomeMy WebLinkAboutMortgage_Adcock e STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNSg Co Township Year
Lire''''' `>, lip
mil, FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(813110-15) ,
'c L Prescribed by Department of Local Government Finance
INSTRUCTIONS:
DEC 2 9 2016 File Mark
To be filed in person or by mail. Fonn fled with:
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the dell s sought
Must be filed or postmarked with the County Auditor or County Recorder of the county 4•r ' ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year- GI R un,,I ,, fi r R County Recorder
2) Mobile/Manufactured Homes not assessed as Real Pm Must file with the Co rht ❑ Court
where the properly is located during the hvelve(12)months before Mardi 31 of each year the deduction is sough
See reverse
number/legal description
ption Recall number Page number
ola�a� � � -ark aS/- fro / aao 00 c_5 cord aU �/ a / 7
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage!Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year .assessment date,current year data of application legal or equitable owner?
a 5 c.oc8 ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than corvwih,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
Mobte Hont(IC 6-1.1-7)
Name of mortgagee or contract seller y3
Address of mortgagee or contract seller(number and sheet,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage -
Address of assignee(number and street dty,state,and ZIP code) ),rt��,\ �� ;C�� a�' 14-
. r- `1 B CocF— -Qi
Does applicant own property in any If yes,what county? What Taxing District-, Sn B R,h,._ . - 1 unt of deduction
other county Drawer NO...a9.\, —�' I-}
in Indiana? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on tht A' a V 1 6 6o . t3 0 rded in the county
recorder's office(including any home equity line of credit that is recorded in the n.
COUNTY Card NO. 1- 1 -, I(
Deduction approved in the amount of
20 20 20 20 20 20 20
Signature of County Auditor County • Date(month,day,year)
-
I 1 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
owner I contract buyer of the aforementioned property on date application is filed.
Sig a vners name) Date(month,day,year)
y , 9 K CF---
Fug resident address of applicant(number and sheet,city,state,and ZIP code)
,----C—o? 01 I C Yto s s C 1— P. 05 1 z_(
Person authorized by duty executed Power of Attorney or by IC 61.1-12-0.7 Date(month,day.year)
Address of authorized person (number and street dry,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.