HomeMy WebLinkAboutMortgage_Bertram (3) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
,� Countttyyy Township Year
FOR DEDUCTION FROM ASSESSED VALUATION ILE
S r r rn Forth 43709(R 1 3 10.16)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: JUN Mark
JUN 2 6 2017
To be filed in Inman or by mail. Form fled
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 coo where : • i•- • minty Auditor ;
located on or before January 5 of the immediately succeeding calendar year. i, :�rmn.
2) Mobile/Manufactured Homes not assessed as Real Property.Must file R;. r > o ❑ 'Recorder
where the property is boated during the twelve(12)months before March 3� S ,or•eduction csase1PRugtzt
See reverse side for additional instructions and qualifications. •
t(oxmergr WILL re reveres side)
�I/1I lin-
T e Key legal -oo0Uq (-ors . Page
Assessed value Meat property as of Mortgage I Contract indebtedness unpaid as of - Mortgage I Contract irxientedness unpaid as of Is the appfirart the sole
assessment date,current year anent year /�� date of application legal or equitable owner?
�.00vvo ❑ Yes ❑ No
If no,what is his I her exact share of interest? / If owned wit 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
❑ Real Property ❑ AnnuafyAssessed
Mobie Home(IC 6-1.1-7)
1.1-7)
Name of mortgagee or contract seller ��}} n°) Je
Address of mortgagee or contract semi(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage '
Address of assignee(number and street rdy,smote,and ZIP code)
Dees applicant own property In any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other in Inds?? ❑Yes ❑No - anent years ❑Yes ❑No
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 egwly fine of credit that is recorded in the county recorders office)that is the basis for the deduction.
COUNTY AUDITOR " - - •
Deduction approved in the amount of:
20 20 20 20 . 20 20 20
Signabae of CoumyAuditor Canty Date(month,day.year)
I 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.
ynahne nets name) m Data(mordh,day,year)
I:resident address of applicant(number and street city,state,and ZIP code)
)° S6o3 iJ6r4l 011 us Ft,_.-( 4f faA21e. ..a iii 4"1646
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street dly state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 510,000.