HomeMy WebLinkAboutMortgage_Bugher a. '% STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
`—
Presorted by Department of Local Government Finance
INSTRUCTIONS:
To be filed in person or by mail. MOT( .fyey
Filing Dates: 1) Real Properly Must be completed and dated fn the calendar year for which the deduction is sought Mi'1 `0 U f/
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ❑ County Auditor
located on or before January 5 of the immediatery succeeding calendar year ❑
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the County Auditor of the county u rder
where the property is located during the twelve(12)months before March 31 of each year the deduction) u�h
See reverse side for additional in�uctionsand qualifications. i SO COUNTY AUDITOR
Appfcant(owner or con':a buyer-see onw side)
�I / . 4, _ `�nw•.1: l._y�� 4. _ Pall
Taxing D4trict f 0-195-caw f�'�3• ? k $p(' Record number 9�S
Assessed value of real property as of Mortg age/Coreaa indebtedness unpaid as of t/I Mortgage/Contract indebtedness unpaiQas7 Is the applicant the sole
assessment date,current year assessment nt date of appf>ration legal or equitable owner?
❑ 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 apprvanl,indicate below • Is the property in question:Annually Assessed
❑Real Property ❑ Annually Assessed
Mobile Home(IC 6-11-7)
Name of mortgagee or contract seller
•
•
A ! . — a . A. . .•
Address of mortgagee or contract seller(number and steel,city,sbte,and ZIP code)
Name of assignee or other owner or holder of mortgage — }(,
t Address of assignee(number and sreek city state, ZIP co ca 5 ( i.)I J(l
odes applicant own property in any If yes,what county? i ]�l;a 1\;C 1^,N n•• --• nested If yes,state amount a deduction
t .:.
in Indiana? ❑Yes El No r - J('-A� ❑No
A person is not entitled to this deduction unless the perm r_. _ / •1 h'5 ' febtedness that is recorded in the county
recorder's office(mduding any home equity line of credit --1 6a t-iltN 0. - " •basis for the deduction.
• • 'V)/iJ..
Deduction approved in the amount o .._ _
_..
f. ..
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.
E5t ?na me) ^ Dale(month,day,yaar)
ddress of applicant(number anand city,state,and Ll pod;)
105 4 w ssD p , Q� ► l, 146s
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12 7 c; 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.