HomeMy WebLinkAboutMortgage_Keil (2) STATEMENT FOR DEDUCTION OF MFROM ORTGAGE ASSESS OR CONTRACT ED VALUATION INDEBTEDNESS County Township Year
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'. State Fort 43709(R13/10.15) Fi Lid
Presabed by Department of Local Government Fnance
INSTRUCTIONS:
To be filed in person or by mait fo rp with:
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought DEC U U I p
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is County Auditor
located on or before January 5 of the immediately succeeding calendar year. • ,•
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the Cou Auditor of the cou•, 7 . 'ecorder
na ded,� L,l• UNTy ,.
where additional instructions is located during the tvrsre(12)months before March 31 of each year the GTtf§•j%,'OUNTY AUDITOR
See reverse side for�1na/d�dirt-ional instrections err MQ�qu��'jeficatiorts.
Applicant ... 'or�6uYer- l .(%�o D
L • D '• - Key number/I description Record number Page number
a0/& ,5/7,3
_•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 date of�appynL/onL /n /� legal or equitable owner?
`{" / / // 50 ID Yes 0 N
If no.what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate belay Is th operty in question:Annually Assessed
"Real Property ❑ Annually Assessed
•Name of mortgagee or contact seller try /`/ // /g �� Mobile Home(IC 6-1.1-7)
Address of mortgagee or contract seller(number and/ --t city,state,and ZIP/c code)
Y�"--
Name of assignee w other `� hold frtrortgage , / I�
did og ' s-/O //ge-
Jr
Address of assignee(n t city,state,and ZIP code)
Does applicant own properly in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other on property for
in Indiana? Yes ❑No current year? 1_1 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 aedit that is recorded in the county recorder's otfiue)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 - I "-- — '
cl-0 l(. — 5/ 73
Signature of County Auditor County
•
I I We certify under the penalty of perjury that the above and foregoing information is tr N 1 ana and
fly owner 1 contract buyer of the aforementioned property on date application is filed. Drawer O
`� Signature(owners M name) y�
. ,,(*nail/%Q�,YG� Card NO
Futrusident address of applicant(number and street,city.state,and ZIP code)
7\ 3853 5 Sao S /-la.r:r)yc4tc -1, /.V '/7(c 31
Person authorized by duly executed Power of Attorney or by IC 8-1.142-0.7 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 him and a half years and a fine not to exceed$10,000. -