HomeMy WebLinkAboutMortgage_Peach STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
=-t1 FOR DEDUCTION FROM ASSESSED VALUATION
State Fan 43709(R13!10-15) .. - -
�'- Prescribed by Department of Local Government Finance
d- irk ; l
INSTRUCTIONS:
To be hied in person or by marl ohm .R -
Wing Dates: 1) Real Properly:Must be completed and dated in the calendar year for which the deduction is sought. Rn
Must be filed or postmarked with the CountyAudtor or County Recorder of the county Inhere the property is J J E2 trio lidi1of
located on or before January 5 of the immediately succeeding calendar year.
Recorder
2) Mobile/Manufachmed Homes not assessed as Real Property.Must file with the County Auditor of the county'
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse a for additional instructions and qualifications. jQ/{1 •
Applicant( buyer-see onre ado /con f� ^^ �� (;IHSON COU Wig(
Assessed Taxing District _—`_r�r-__v- t -a`o/l•3 — •lM.•a/vIt. �l/''L' 10.028 Record (/� '! U (
Assessed value of real properly as of ,""'CJ"Jl�Mortgage f�Contactyl indebtedness unpaid as of - Mortgage!Contract indebtedness unpaid as of Is the applicant the sole
assessment dab,current year amassment date rrg0[year_ , z date of application tegaf or equdable owneR
l/IJ� fVl l/V"�/V1/Vl ❑ Yes ❑ No
If no,what S his/her exact share of interest? It owned with someone other than cpm Mr.,indicate with whom
If name on record is/afferent than that of applicant indicate belowc Is the property in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
1{
Mobile Nome(!C 6-1.1-7)
Name of nrodgagee rfi seller)
Address of mortgagee or contract seller(number .•.--t,city,state,and ZIP code)
.
Name of assignee or other owner or holder of mortgage ' _
Address of assignee(number and street,ray,slate,and ZIP cod r
other courdy Does apparent own property in any 't yes.what c o u n t y? - Drawer N O.. ° CI. tested Ij yes,state amount of deduction
d ❑
Indiana? Yes El No ❑No
A person is not entited to this deduction unless the perso l ebfedrhess that is receded in the county
recorders office(including any home°gully fine of ere&f Card NO basis for the deduction.
Deduction approved in the amount at -.• 20 20 20 20 20 20 20
/ _
� .
Signature of Coady 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/contact buyer of the aforementioned property on date application is filed.
(owners bra name) 'i//n Data(month,day,year)
Full resident( 3 appagnt_(na11e and street cd};state,am{t{�'1F Dods) I O
Person authorized by duly Sexec tied of Attorney or by IC 61.f-12--00.7_➢'�V�\ {/0_ Date(month,day.year)
Address of authorized person (number and sheet,a c state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a hall years and a fine not to exceed$10,000.