HomeMy WebLinkAboutMortgage_Douglas (6) E. . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
:- State Form 43709(R13110-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
lb be filed in person or by mail. i F•;i w101,
Filing Dates 1) Real Properly Must be completed and dated in the calendar year for which the deduction is sought 1 I
Must be filed or postmarked with the County Auditor or County Recorder of the county where the pm is i I I I -�•r•• ditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the tout
where r properly is located during the twelve(12)months before March 31 of each year the deduction is so I
See reverse side for 1'••• al instructions and qualifications.
Applicant(owner., cons. . • - - A I -verse y-) •
a _ V�u11f ` 1 Cti.: I £.I1 f_L .1.. JAL] is 4 l • ':mri�'
Key i GIB' /IV!' ' :I- 'i-
number! •-r
I ' / `I b-Id o 'tioi-cod. io(--o • - ►_(, .38
-of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessmeN date,current year assessment date,a date of application legal or equitable owner?
r .o 00 ❑ Yes ❑ No
If ro,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 below- - Is the property in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller �c�'.1 ��yG-O �.((.'y�.r --Cin_---
Address of mortgagee or contract seller(number a T� 'IV ) t
Drawer NO..'QW..P.,.•,.
Name of assignee or other owner or holder of mon .
Address of assignee(number and street city,stet. ' Card NO. "3(
`fF I SIcc^ R�
Does applicant own property in any If yes,wha,...._...,. /
leen requested If yes,state amount of deduction
other in Indiana? ❑yes ❑No I I eurrrent yearrt LI 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 fine 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
Si. to '• i. my• •Poor• / / County Date(m
I t We certify under the penalty of perjury that the above and foregoing information is and correct and that the applicant is a resident of Indiana and
owner!contract buyer of the aforementioned property on date application is filed.
Signature(owners full name) J (� 1 1 Date(month,day,year)
4 Qe •f\_lull..._ ell.rsJc%e.!/-
/a-3o- 1 �
"r• t=prc ppfxan�'m�bVer•�an',dl; nil (F.pad eaten,
Person authorized by duty exeaited Power of Attorney or by IC 6-1 A-1112•-0.77r— 1/4,q41171170 Date(month,day,}ear)
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. .