HomeMy WebLinkAboutMortgage_Devoy (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
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FOR DEDUCTION FROM ASSESSED VALUATION County Township Year
°° State Form 43709(R13/10-15)
Prescribed by Department of Local Government Finance
FILE
INSTRUC77ONS: File Mark
To be filed in person or by mail. Form filed with:
Filing Dates 1) Real Property Must be completed and dated in the calendar year for whi pia: .; •udj) sought. ,.,
Must be filed or postmarked with the County Auditor or County Recorder. . : ..may where the property is L'f County 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 w)q)the.Co . of the county
where the property is located during the twelve(12)months before March deduction is sought
See reverse side for additional instructions and qua ilfications. GtggnN COUNTY AUDITOR
App&znt(owner ct�bu��yerrrs'e� ,ys on reverse side)
T District Key number! description �� // Record/u / r Pagg 1
Q .c -csbn-7=2 CO
Assessed value of real' rty as of Mortgage!Contract indebtedness unpaid as of Mortgage i Contract indebtedness unpaid as of Is the applicant the sole
assessmeM tlate, year assessment date, n�tyear date of application legal or equitable owneR
v non ❑ Yes ❑ No
If no,what is his 1 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
❑ Rea)Property ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
6j)nyi //n/)'
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage -- C , / _
Address of assignee(number and street city,state,and ZIP bal./L7� Dc U7t) R
1
Does applicant own property in any If yes,what county? S U SA N A ested If yes,state amount of deduction
Ind iana?
of er county ❑
in Yes ❑No 1
A person is not entitled to this deduction unless the pr I -58 ]No
rbtedness that is recorded in the county
recorder's office(including any home equity line of cm basis for the deduction.
..vvn. I m.. ..v..
Deduction approved in the amount of.
20 20 20 20 20 20 20
Signature of my nor t Q Couni�� Date(month,d yeah 061-0 —17
at/Ain C I e certify under the penalty of perjury that the4o foregoing information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed. �r/./
Signature l n Date(month,day,year) /
i � ���Z�,
F resi0 i dtlress a t(nrm+ and street illy,state,and ZIP code)
i PErson authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 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. •