HomeMy WebLinkAboutMortgage_Seibert � a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
.Y - :h FOR DEDUCTION FROM ASSESSED VALUATION
7,.4}�.- State Form 43709(R13/10-15)
Presatbed by Department of Local Government Finance
INSTRUCTIONS: yg File Mark
To be filed in person or by mail. q Form filed with:
Filing Dates 1) Real Properly Must be completed and dated in the calendar year r n e sought
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 caendatl ill'LZ 017 ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file a wily Auditor of the county
where the property is located during the Melve(12)months before Main,31 of each year the deduction is-sought
See reverse side for additional instruction and qualifications.
AppSant(cam conBrgr oaapuyer-see
�(� S COUNT/Y�AUDITOR �7 /
Taxing District �'J (_/ 1/! II Ioo- l%O3r g5coa1 number[ �faSb
Assessed value of teal property as of V`�Mortggagee//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 application legal or equitable owner?
19 04 (J(JOO ❑ yes 0 N
If no,what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is(afferent than that of app i diate belwr. Is the property in question Annually Assessed
n � ❑Real Property ❑ MnnuellHo Assessed
J1- Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and street city,state,and ZIP code) - -- __
Name of assignee a other owner or holder of mortgage 5 ET L "T D rte
Address of assignee(number and street,city,state,and ZIP code) 1[ (/ 1l
Does applicant own properly in any If yes,what county? What Taxing L I (7- 15 our of deduction
other county
in Indiana? ❑Yes ❑No '
A person is not entitled to this deduction unless the person has a balance o .c_e.,u,contract indebtedness that is recorded in the county
recorders office(including any home equity tine of credit that is recorded in we 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 coned and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
ignature t�ag.: e) _ Date(month,day,year)
esid Xf 51 a i r`85 j u) QIiQ,JeWtEIe tj 219-c2cto-b
Person authorized by duly executed Power o they or by IC 1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
The penalties for penury can include imprisonment up to two and a half years and a fine not to exceed$10,000. .