HomeMy WebLinkAboutMortgage_Dougherty STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
; '.- State Form 43709(R13/10-15) Ed /;
1° I 5
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Prescribed by Department of Local Government Finance _
INSTRUCTIONS: K>e File Mark
To be filed in person or by mail. DEC 2 9 Form filed with:
Filing Dates: 1) Real Properly.Must be completed and dated in the calendar year for which the deduction is sought's1U
Must be filed or postmarked with the County Auditor or County Recorder of the cop -re the property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar yew /- 4 .
2) Mobile/Manufactured Homes not assessed as Real Property:Must his with the I f o h�rr orityyy f:coup ❑ County Recorder
*hem the properly is located during the twelve(12)months before March 31 of each year lei.,-•r. •s is sought
See reverse side for additional instructions and qualifications. )TOR
Applicant(owner or boa buyer resaiUipds on reversee side)
r NtrictR '/ Key number/legal phones pp�-1 �/ Re )n -r Page number •
Assessed value of real p•' as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole •
assessment date,anent year assessment data current year date of application legal or equitable owner?
❑ Yes ❑ No
If no.what is his/her exact share of interest? I If owned 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
$eal Property ❑ AnnualyAssessed
• /� //J� — // / Mobile Home(IC 6-1.1-7)
Name W coo gee 10*/7G sell 71 1�n^�-7\ �/c-r-C1Y2C4aY n✓/02ZUXd
Address of gagee or contract seller(number and abheetGH site,and ZIP cede)
Name of assignee or other owner or holder of mortgage
iJ„
Address of assignee(number and street,city,state and DP code)
Does applicant own property in any If yes,what county? Mat Taxing District? Has this deduction been requested If yes,state amount of deduction
other county property for
in Inndi ❑Yes ❑No on 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 equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 20 20
Signature of County Auditor County • Date(month,day,year) •
•
I/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/contract buyer of the aforementioned property on date application is filed.
Signat�hN namej� s / Date(r,wbr,day,year)
Full resid of app (n d stree,dl}:state,any�P code) t CST / 7476
��u � �I2-0.7 r
Person a onzetl tlay rxewtetl Power of a or by IC 1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet 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. •