HomeMy WebLinkAboutMortgage_Keller (5) s STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
; FOR DEDUCTION FROM ASSESSED VALUATION
tr•- State Form 43709(R1311415) ED
• " Prescribed by Department of Local Government Finance I
INSTRUCTIONS:
File Mark
- Totie filed in person or bymait. MAY 25 •'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 County Auditor or County Recorder of the courtly where the property is ❑ County Auditor
located on or before January 5 of the immedraMy succeeding calendar year. .ii County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of th.F W/m
' 1/r
where the property is located during the twelve(12)months before March 31 of each year the el- cur .'r n"z e T • 1 . @ -
See reverse side for additional instructions and qualifications.
(ovmer or conaaaZseee " rs�on reversesjde)
T ' D"5trict Key number I legal description Record number Page number
641 -0_.) a62 ' oa - 5g- o30 - 000. 9f3 -oil ,1017 A 0 3
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of apptiori n legal or equitable owner?
f Orr Doo ❑ Yes ❑ No
If no,what is his I her exact share of interest? It owned with someone other than cpvrse,"iWiere with whom
If name on record is different than that of apparent,indicate below- - Is in question:Annually Assessed
Real Property 0 Annually Assessed
_ - Mobie Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
Drafter N
Name of assignee or other owner or holder of mortgage O••.. ..�1��I
Address of assignee(number and street city,slate,and ZIP code) Ca I'd
NO ..
•Does applicant own property in any If yes.what county? What Taxing District? Has this deduction been requesteo •� con
other ❑Yes ❑No curren year? ❑Yes- 0 No I. .
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/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 uyer of the aforementioned property on date application is filed.
Signature �na [�/ Date(month,day,year)
'/ r/ %%,
—57 ss/ZOI/�
r[ FrCI d a t(number street city,silts,and LP code)
!` 898 /■ 7 76(710
P authorized by duty executed Power of Attorney orofy IC 6-1.1-12-0.7 Date(month,day.year)
Address of authorized person (number and sheet ay,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.