HomeMy WebLinkAboutMortgage_McClain a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION F 4 1 E
'� State Forth 43709(R13/1415)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail MAY 1.0 2017 Form filed with:
Filing Dates 1) Real Property:Must be completed and dated in the calendar year for Mtn the deduction is sought
Must be filed or postmarked vWth the Courtly Auditor or County Recorder of the county - : th- .:.,.•• ' County Auditor
located on or before January 5 of the immediately succeeding calendar year. ' 4111A�;
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the Cou�• /i i,4141 : ❑ County Recorder
where the property is located during the twelve(12)months before March 31 it.•c..:n,. 0 t:!';7t!„2-��
See and reverse side for additional instruction
id s and qualifications.
Taxing District Key number l legal description Record number Page number
Lit J4 C2L / 9 -r3 / 009000 170d ? c O/7 i&'6q
Assessed clue of real property as of IMortgage I Contras indebtedness unpaid Mortgage I Contract indebtedness unpaid as of is the applicant the sole
assessment date,current year assessment date,parent year date of application legal or equitable owner?
7S006 ❑ yes ❑ No
it no,what is his/her exact share of interest? If owned with someone other than spn!mP,indicate with whom
If name on record a different than that of applicant,indicate below: - Is the property in question:Annually Assessed
• a)Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller G/
3
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) .
i
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 Taxing Dis �_�!•'• ^ it of deduction
other aunty 10 (il(\
in Indiana? ❑Yes ❑No I o
A person is not entitled to this deduction unless the D 1�\.C� l mil•• in the county
pe person has a balance on tr
recorder's office(including any home equity line of credit that is recorded in the, •_ ion.
COUNTYA a\O•
Deduction Dedu approved in the amount of COY - -. - - -
20 20 20 20 I 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 aforementioned property on date application is filed.
Signature�(owner's full"name) Date(month,day,year)
— �
)° -r— b. 241-SCG -
Fug resident address of appfcant(number and steelftty state,and ZIP code)/ / / T I/ [��x
7° 3o, so., 7'� C, 4 H'-en 44e /(! G Is T4 all /" 7 l (3 7
Person authorized by duly executed Power of Attorney or by IC e-1.1-12-0.7 I 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.