HomeMy WebLinkAboutMortgage_Dyer �a STATEMENT OF MORTGAGE OR CONTRACT OI4 is .unty Township Year
' FOR DEDUCTION FROM ASSESSED VALUATIO 1
.A.,..- State Form 43709(R13/10-15)
Presmbed by Department of Local Government Finance
INSTRUCTIONS: AUG 7 2017 File Marx
To be filed in person or by mail. Form filed with:
Filing Dates. 1) Real Property Must be completed and dated in the calendar year for • he de ught
Must be filed or postmarked with the County Audrtor or County qRe1qcgo�rdee the property is Q-County Auditor
treated on or before January 5 of the immediately succeeding h1'L'sYfileCO U NTY AUDITOR
2) Mobile/Manufactured Homes not assessed as Real Properly a wrth the County Auditor of the county County Recorder
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant(. .-> or contract buuyyerr--see resaictrns on reverse side)/, /(�)
/MIL,"£f' 47� 9- SA� ;Q./LCt4"t,c( M 4; it
T- ;ft J. Key number/lei des .ptien Record number
Page number
41 Mf c to-/J-i3 -070471 - y s4 8' oa f 33x3'3
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,=rent year assessment current yea date of application legal or equitable owner?
r73C) 0 Yes 0 No
If no.what is his/her exact share of interest? If owned with someone other than spouse.indicate with whom
If name on recad is different than that of applicant,indicate below Is the property in question:Annually Assessed
❑Real Property ❑ MnualiyAssessed
• Mobile Hone(IC 6-1.1-7)
Name of mortgag`ee or contract contract seller 1 //
Address of nor rtgagee or contract seller(number an street city,state,and P code)
Name of assignee or other owner or holder of mortgage 3 V E)2J --'7 '� .0
Address of assignee(number and sheet dry,state,and ZIP code) tl���'CC��JFi4 twig E a)
Does applicant own property in any If yes,what county? What Taxing Distil? f /_3 3 3 3 of deduction
other county
in Indiana? ❑yes ❑No
A person is not entitled to this deduction unless the person has a balance on the p din the county
recorder's office(including any home equity fine of credit that is recorded in the hoc..,
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 I contract buyer of the aforementioned property on date application is fled.
Signature( e) Date(month.day.yew
Full resident address of applicant(number and sheet dry,state,and ZIP code) /� -/ '
80 9 w - , ssaA/ AI/e , R-r:vr Word !Ai 'i'767(7
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,stale,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.