HomeMy WebLinkAboutMortgage_Martin (35) RQ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
, . FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15) 2017
cc Si._-i4 Prescribed by Department of Local Government Finance �� File Mark
a.
i I
INSTRUCTIONS:
To be filled in person or by mail. • 1 ed 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 county where the JUL 2 0 21-ii ❑
property is located on or before January 5 of the immediately succeeding calendar year. County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property: Must file with the CountyAuditor o the ❑ County Recorder
county where the property is located during the twelve(12)months before March 31 of each ye; "e • _,
deduction is sought. GIBSO I writ A
See reverse side for additional instructions and qualifications.
COUNTY VDITOR
Applicant(owner or contract buyer-see restrictions on reverse side)
Charles A. Martin
Taxing District Key number/legal description 26-04-25-102-000.072-020/106 S Main St. Record number Page number
Patoka, Indiana 47666 /1 JOo ?
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 application legal or equitable owner?
$49,300.00 ?Yes ❑ No
If no,what is his/her exact share of interest? If owned 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
SP Real Property 0 Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Fifth Third Mortgage Company
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
5001 Kingsley Drive,Cincinnati, OH 45227
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state, and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of
other county on property for deduction
in Indiana? ❑ Yes �No current year? ❑ 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 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 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 bu er of the aforementioned •ro•ert on date a••lication is filed.
��,,, lure •• - r Date(mont ,day ear)
lf� ,.,, 7(mont
'Full resident address of applicant(number and street,city, state,and ZIP code) 1
106 S Main St., Patoka, IN 47666
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,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 S10,000.