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HomeMy WebLinkAboutMortgage_Pegram a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year ", -- ' FOR DEDUCTION FROM ASSESSED VALUATION G .7A� ` State Form 43709(R13110-15) S :1 Presaibed by Department of Local Government Finance 7 4C1 : Ma IHSn:udin per: F �( ; lb be filed in person or by mail. 1 YYY vr�tr: Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is FE: R glib Auditor located on or before January 5 of the immediately succeeding calendar year. 2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the CountyAuditor of the county County Recorder where the property is located during the twelve(12)months before March 31 of each year the deduction is sough twit See reverse side for additional instructions and qualifications. ' 40111,11. Applicant(owner or contract buyer- MS!cdorrson reverse side y\ n r'.�-`/'y/�1 ��,.- G(ggON COUNTY aUDITCR Taxing District nu /legal F/ 1'`-4 1 Record n r Page numbs a —rq-1j- lo3— �oo.aos -©a� 5a�8 Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaitl as of Is the or equitable m the sole assessment date,anent year assessment data,current year date 3a� legal w equitable owneNT d ❑ Yes ❑ No If no,what is his I her exact sham of interest? if owned with someone other than spouse,indicate with whom If name on record is di ferent than that of appilcant,indicate below. Is the property in question:Annually Assessed ❑Real Property ❑ Annually Assessed Mobile Hone(IC 6-1.1-7) Name of mortgagee or contract seller /V}*]+9 M Address of mortgagee or contract seller(number and street. ,state.and ZIP code) Name of assignee or other owner or holder of mortgage Address of assignee(number and street,city,states.and 710---. ,...1 cLww%t C'. 4 fie.\\.1 L.Pero-Nr Does applicant own properly in any If yes,wh t been requested If yes,state amount of deduction other county 4'o �r �� '°� � LL in Indiana? ❑Yes ❑No ]Yes 0 N .4 person is not entitled to this deduction wit ntract indebtedness that is recorded in the county recorder's office(including any home equity f( \ai., b a 6- O c) c tat is the basis for the deduction. ao1 o - 5a95 Deduction approved in the amount o \a.' k� - I �' Deduction f - - - 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 correct and that the applicant is a resident of Indiana and owner I contract buyer of the afore tioned property on date application is filed. cre(owners full name) 1 1y�}/�� Date(month,day,yeah .dt��t address of appliant(nu ben sdEet, .state,an�P code) n 4 auifi ed b�duy executed Power of Attorney or by IC 6r7.1-12-0.7 Date(month,day,year) Address of authorized person (number and street city,state,and ZIP code) The penalties for perjury can indude imprisonment up to two and a half years and a fine not to exceed$10,000. .