HomeMy WebLinkAboutMortgage_Siekman (5) 't STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10.15)
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---- Prescribed by Department of Local Government Finance ��
INSTRUCTIONS: File Mark
To be filed in person or by mail. b� Fonn filed with:
the calendar year for which the d�Qy�{r' i
Must be filed or postmarked with the County Auditor or County Recorder of the the property is ❑ County 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 My Au ' e county ❑ County Recorder
'stem the property is located during the Melva(12)months before March 31 of a rs t
See reverse side for additional instructions and qualifications. H COtINTy AUDITTU^
Appfiram(gµm p dryer-,see �on reve sa,)Jai^ ,1 1tn •
Ta,ongibsthot`r/,, O_(/(� umber i legal description '{CJ,>/_�/- "-/ I(r�,l( Record number Page number
A/ 930 a QO, 5 0735/
Assessed value of real property as of Mortgage I Courant indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment dabs,current year assessment date,current year date of application - legal or equitable owner?
❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than wise indicate with whom
tf name on record is different than that of appliicant,indicate be Is the property in guestiorn Annually Assessed
a61-,3 -a.6-300 -DD(- '7sa.tut to eal PrOperty ❑ Annually
Nbble rre(Assessed
Ho 6-1.1-7)
Namet ofimortgagee or ft viler
m
Address of mortgagee or contract seller(number and street ay,state,and ZIP code)
Name of assignee or other owner or holder of mortgage � �r�J� �
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Address of assignee(number and street dry,state,and VP code) Drawer NO
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Does applicant own property in any If yes,what county? What Taxing District? , 5--S I 'action
other county Card NO.
in Indiana? ❑Yes Ell No
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A person is not entitled to this deduction unless the person has a balance on the perm "I-9( ...,.no rs reouraea in the county
recorders office(including any home equity line 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
Signature of County Auditor County • Date(month,day,year)
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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 aforementioned property on date application is filed.
Signs re(owners fu name) Date(month,day,year)
)-aTh > A� rciii2.r,-ua.I z-a5- 7
Full resident address of lcant(number and street city.state,and ZIP code)
3330 5 750 E Francisco , t&) N-)tagq
Person authorized by duly executed Paver of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street oily,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.
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