HomeMy WebLinkAboutMortgage_Elliott (6) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
. FOR DEDUCTION FROM ASSESSED VALUATION
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State ibed 43709 Department 5)
`- Prescnbed by Department of Local Government France PI• : I I )m•
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INSTRUCTIONS:
To be filed in person or by mail. Forrm, filed with:
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought D E u 9c' n is
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is 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 County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sough
See reverse side foi additional instructions and qualifications. CIBSOP.' CQU ITV Al In1T(1R
Applicant(owner or co ct r- restrictions on re
S ' 2" -i 0 '000rF,tis ?-'oat dc�i� n1u73
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 date,current year assessment,currer ear date of application legal or equitable owner?
S ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom
tf name on record is different than that of applicant indicate belay. Is the property in question:Annually Assessed
❑Real Property ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 2 P 1
Address of mortgagee or contract seller(number and street.city,state,and code)
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Name of assignee or other owner or holder of mortgage e -
Address of assignee(number and sheet,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 prosy for
in Indiana? ❑Yes ID No current year? ❑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 tine of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COU 821-651:L / � � �/��� /�
Deduction approved m the amount of: I 1�h l.C.,
20 20 20 2( 20
to—
Signature of County Auditor I ���� r,day,year) •
I/We certify under the penalty of perjury that the above and foregoin( a resident of Indiana and
owner!contract buyer of the aforementioned property on date applica ........_
Sig re corers fullyart/e) � i___ _ h,day,year)
P� -vl
Fug r ent address of apprcant(number and street,city state.and ZIP code) /
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Person authorized by duly executed Power of Attorney or by IC 41.1-12-0.7 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. - - -- _