HomeMy WebLinkAboutMortgage_Brock sT STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
i t.1 FOR DEDUCTION FROM ASSESSED VALUATION
'. State Form 43709(R131 10-15)
Prescribed by Department of Local Government Finance IMIIIMP11111
•INSTRUCTIONS: Fi( ,.
To be filed in person or by mail. FDorrn filed with:
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought FEyJI c�o31�d
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is uditor
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
whem the properly is located during the twelve(12)months before Mardi 31 of each year the deduction is sought,)
See reverse side for additional instructions and qualifications. _disk , T�
Apperant(owner orcontradbupn ` • " scfl CIBCON COUNTV a nu Record nu r m Al its ` Record-ODa. 196-O 9 1 P . 79
Assessed value of real property as of l Mortgage!Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year 1 assessment date,current year dafa•yap tqn_ legal or equitable owner?
Of/l/r/1 l/XfJ/r�/n ❑ Yes ❑ No
0 no,what is his/her exact share of interest? If awned 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 ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller ^ a
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taring District? I Nano-' - )pasted If yes,state amount of deduction
other county
in Indiana? ❑Yes 0 N El No
A person is not entitled to this deduction unless the pen-•-- - 1 • "••• 'ebtedness that is recorded in the county
recorder's office(including any home equity line of c D r a`�.�l• ••'' •• or 5asis for the deduction.
Deduction approved in the amount of •'-`.'tin•/'
g6 `
20 20 20_ I 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 correct and that the applicant is a resident of Indiana and
owner!con.-ct buyer of the aforementioned property on date application is filed.
S• (•. :fr (name) Date(month,day,year)
Fut '.•dress of applicant( g,- nd street city,state, . d ••••e)
i
I.__I I at 4. w • IA ii. ! ( IA A •
Person mini-axed by duly executed Power of Attorney or by IC 6-1.1-12 1.7 Date month,day,year)
Address of authorized person (number and street city,slate,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed S10,000.