HomeMy WebLinkAboutMortgage_Chapman (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
5t FOR DEDUCTION FROM ASSESSED VALUATION
\� State Form 43709(Rt3/10-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. Form feed 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 o -..rd- • -ounty where the property is ❑ County Auditor
located on or before January 5 of the immediately su tr..n.l ,ndar.r. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real P{•p- l the t my Auditor of the county
where the pmpeny is located during the twelve(12)m. s b - -- 4 year the deduction is sought.
See reverse side for additional instructions and qualifications. -
Applicant(owneror contract buyer-see restrictions on reverses/de) AUG 22 2017
MARCIA K. CHAPMAN
Taxing District Key number/legal description �y� Recos;numbe Page number c-�
WHITE RIVER 26-04-23-300-000.190-01$18Idt 42-00 (6,� /)Q1 d
Assessed value of real '•• rryg�ITOFd 3
property as of Mortgage tdat ,current - �LIAb�( 1idat ct indebtedness un id of Is or equant the sole
dare,current year assessment date,cortent year date of application legal or equfable owner?
$93,620.00 13 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 deferent than that of applicant.indicate below: Is the property in question:Annually Assessed
GI Real Property ❑ Annually Assessed
Mobile Horne(IC 6-1.1-7)
Name of mortgagee or contract seller
ACCEPTANCE CAPITAL MORTGAGE CORPORATION
Address of mortgagee or contract seller(number and street,city,stare,and ZIP code)
101 PLAZA EAST BLVD., SUITE 103, EVANSVILLE, INDIANA 47715
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 deduction
other county on property for
in Indiana? ❑Yes LJ 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 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 filed.
Si na ure wner's futl name) Date(month,day,year)
�j� � /� n4c-, � 08/ 15- /2017
FNI reside address of applicant(number and sty,state.and ZIP code)
3600 N. 225 W, PATOKA, INDIANA 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$10,000.