HomeMy WebLinkAboutMortgage_Grimes STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
..'. State Form 43709(R13 1 10-15) Yq® g®®
�— Presalbed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be riled in person or by mail. MAY 2 3 2017 Form filed with:
Filing Dates 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought gyp,
Must be filed or postmarked with the County Auditor or County Recorder of the co cute ' th= ..., is LJ County Auditor
located on or before January 5 of the immediately succeeding calendar year. j; ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the c•• 'i''tag!?re ,
where the property is located during the twelve(12)months before Mani if3YFrb8�3J�r -t '`- !1.'ry'I is sought
See reverse side for additional instructions and qualifications.
Applicant(o/wer orr contract r-srZns on reverse side) P _ n / •
/ Key number/legal description -c Record number Page number(l_
J�Il2u�QL� Z!o �,3 C o acv ocr� syc� c ego !7 I e
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
//0 075 ❑ Yes Duo
U no,what is his I her exact share of interest? If owed with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below- Is the property in question:Annually Assessed
`3da.al Property ❑ AnnualiyAssessed
Mobile Home(IC 6-1.1-7)
Nam-of mortgagee or contract seller •
-It_ SLe ..' i i .- / l/�1� - -
Address ofnartga. r(number and street,city, - and ZIP code)
Name of assignee or offer ovmer-or holder of mortgage Drawer N (POI .•
Address of assignee(number and street,city state,and ZIP code)
Clod NO.
/
Does applicant own property in any If yes,what county? What Taxing District? Has this di.___ •'' '''••
other ana? ❑ oeprnt ❑mindian Yes ❑No current year? Yes ❑No j _
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's 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)
•
I f 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 1 .•ntract buyer of the afore tinned pro rty on date application is filed.
Slgnatur> •- t - I -- e) Date(month,day,year)
F •eM address ofa•• t caberantl 0723( cl
( city,slate,and ZIP code)
-05
•- • authorized by duly executed Power of Attorney or by IC 5-1.1-12-0.7 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. •