HomeMy WebLinkAboutMortgage_Ferguson s STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION T T
State Form 43709(R13/10-15) AR 19L/A—IJ
Prescribed by Department of Local Government Finance •
INSTRUCTIONS: q 2017 File Mark
lb be filed in person or by mall. APR 2 7 Forth filed with:
Filing Oates' 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 a propel i d ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. 4 fl County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Au., :'. 4T .
where the property is located during the twelve(12)months before March 31 of each siege,:•.' .' ks -t DIT O
See reverse side for additional instructions and qualifications.
Appft ant(owne�oonUaac buyer-see resaicOwu on reverse side)
T g District (('' Key number/leg esaiption Rend number Page number
no . c a, I - 13-19 - acct - coo 199 OG5 aCJ1-7 X557
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of t Is the applicant the sole •
accac;ment date,current year assessment date, m
,current year date of application legal or equitable owner?
/
5 c0 -]00 ❑ yes ❑ No
If no.what is his I her exact share of interest? If owned with someone other than epni,se,indicate with whom
If name on record is different than that of applicant indicate below: Is the property in question:Annually Assessed
�'Ra�Property ❑ Annually bie (Assessed-1.1-7)
Name of rrongagee or cpryaa seller �`' —
lK\ �- rrr'''111
Address of mortgagee or contract ter(number and street.pry state,and ZIP code) _ O 1 .
Name of assignee or other owner or holder of mortgage
V
Address of assignee(number and street,dry,state,and ZIP code) V
Does applicant own property in any If yes,what county? What Taxing District? Card`O.
.-.,,count of deduction
other county
in Indiana? ❑yes ❑No _j no
A person is not entitled to this deduction unless the person has a balance on the per „-ur contract indebtedness that is recorded in the county
recorder's office(including any home equity line of aedit that is recorded in the corm, ,ecorder's olTn e)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 correct and that the applicant is a resident of Indiana and
owner!contract buyer of the aforementioned property on date application is filed.
Sig (owners full name) Date(month,day,year)
etMpinx. ti/a� /1Z
applicant(num d city,state,and ZIP code)
Iel I°• 1 5k-. RR.e.a(.asw 1tO 9Z4,,CQ N. box a8l
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.