HomeMy WebLinkAboutMortgage_Meuser �> STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Townshi Year•'.-` 1 FOR DEDUCTION FROM ASSESSED VALUATION I A D
State Form 43709(R13110-15)
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INSTRUCTIONS: 91 s -I I
To be filed in person or by malt Form filed with:
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 Courtly Auditor or County Recorder of the county where the property is 4 El - ;, ' •• •r
located on or before January 5 of the immediately succeeding calendar year. ,• •• 'igm-t r
is - r�r�et
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the CD$S O N t. a N.•y • b I I OR
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant owner or contract buyer-see re-• . on reverse side)
t 1LJ-t 01.9 r x�1--
T D' SAY !legal description Record number Page number
is -.t1.3 -ant) — can ( . 1 D9--c op t 5 a, J
Assessed value of real property as of Mortgage!Contact indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the applicant the sole
assessment date,au ant year assessment date,current Year date of application legal or equitable owner?
7 ri s'b kg Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom
if name on record is different than that of applicant indicate below. 1 the property in question:Annually Assessed
Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
N me of mortgagee or contract seller •
Address rtgagee or contact seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage —
Address of a Dra))'er 1`r .•
5signee(number and street a7y,state,and ZIP code) o,
other county own property in any If yes,what county? What Taxing District?
card(Nro, •• croon
in Indiana?y ❑Yes No 1
A person is not entitled to s deduction unless the person has a balance on the person's moray._, •• • I re county•recorder's office(induding any home equity the of credit that is recorded in the county recorder's office)u•.. - •
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.
VCSlignature,(o s full neon e) Date(month,day,year)
Fun resident address of applicant(number and street,city,state,and ZIP code)
IP VIcF 5 r7S E Pit-LA/cens, .1-A./el if7us2o
Person authorized by duty executed Power of Attorney or by IC 6-1A-12-07 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.