HomeMy WebLinkAboutMortgage_Brown � STATEMENT OF MORTGAGE OR CONTRACT INDEBTED E • my Township Year
,Lvt' ' FOR DEDUCTION FROM ASSESSED VALUATIO ,ri
State Form 43709(813110-15) I
Prescribed by Department of Local Government Finance
INSTRUCTIONS: JUL 2 8 2017 File Mark
To be filed in person or by marl Form flied with:
Filing Dates: 1) Real Properly:Must be completed and dated in the calendar year for which the deductio• is . .
Must be tiled or post marked with the County Auditor or County Recorder oftheg !r'4.:pmperryis �County Auditor
boated on or before January 5 of the immediately succeeding calendar year. j'
2) Mobile 1Manufachaed Homes not assessed as Real Property.Must Cake drtAor of the ❑ County Recorder
where the property is located during the twelve(12)months before 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Appipnt(owner or mntrad buyer-see restrictions on reverse ..� - 1
Y)) aI2.-)'� �" ,D a rd `it/2"oz.rA0
Taxing Disbict Key number/legdescription Record number Page number
N f C� I 2 (Oil 9 / F ;3 og9 -oa Co Of7 - 3 / 8/
Assessed value aired pnmperry as of Mortgage/Contract chdebtednes unpaid as of - Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,ascent year �tdate,amend year date of application legal or equitable owner
/JOa3. 2f ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with.someone other than consign,indicate with whom
If name on record is different Man that of applicant,indicate below: th
Is� ee property In question:Annually Assessed
/Pled Property ❑ ArnuallyAssessed
Mobile Home(1C 6-1.1-7)
Name of mortgagee or contract setter Jr/3
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) .
-
Name of assignee or other owner or holder of mortgage '
. Drawer NO... 1. ..`...t...... u
Address of assignee(matter and street try,state,and ZIP code) • G I
Does applicant man property in any t yes.what county? . What Taxing District? Has this der
other courdy Card NO. `;�14 on property
in Indiana? ❑Yes 0 N
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
rout/roues office(Indudug any home equity fine 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/contract buyer of the aforementioned property on date application is fled.Signature wn
(o " Date(month,day,year)
RID resident address of applicant(number andf�`'°�state,and ZtP code)
.ic 9 01 E- 1, )O Q/l" 1 rA 5-, Aa y76.12-
Person authorized by duly executed Power of Attorney or by IC 61.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city y,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 310,000.