HomeMy WebLinkAboutMortgage_Davis (13) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
,; FOR DEDUCTION FROM ASSESSED VALUATION
•,,! '^ State Form 43709(R731t47��
Prescribed by Department of Local Government Finance J
INSTRUCTIONS:
J.L.J FCr�
To be Filing Dates: Real Property.Must be completed and dated in the calendar year for which the deduction is sought O C T 1 r`� i r '-
Must be filed or posbnarked with the County Auditor or County Recorder of the county where the property is ❑ County Auditor
/orated on or before January 5 of the immediately succeeding calendar year. 1_•- • •ecorder•2) Mobr&e/Manufactured Homes not assessed as Real Property Must file with the County Auditor of the co • •. -q •
•
r ;
whem the property is located during the twelve(12)months before March 31 of each year the dedurrnf �., AUNTY AUDITOR
See reverse side for additional instructions and qualifications.
Applicant(owner Vac/ pryer-sqt varx de ^ 7��Q o /C.[
Taring District ��L/ls '•.7�pisrS�t Key nu•. 1 tdyl[a]t/p— $ -ao lVV{_ R'�/1 o. 416-ear R /number �3 f-71
1
Assessed value of real property as of I e/Contract indebtedness unpaid as of Mortgage!Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year asssment data,lx ire date of application legal or equitaNe owner?
S 3 ❑ 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
❑ Real Property ❑ Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or con bad seller ft C3
Address of mortgagee or contract seller(number and sheet c4};state and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP cwt 119/ 7- 2 d
Desapplicant own property in any If yes,what county? v/ / / quested If yes,state amount of deduction
in Indiana? ❑Yes 0 N ❑No
A person is not entitled to this deduction unless the Pe Drawer N O ndebtedness that is recorded in the county
recorder's office(including any home equity line of as ie basis for the deduction.
I
Deduction approved in the amrxmt of: Card NO.
20 20 20 I au_ I 20 20
Signature of County Auditor County Data(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 filed.
S�fu pJ K Date(month,day,yew of II i L I. 11 1 \ um street,c+h? °tiviLi7bYf ill \
Pars authorized by duy executed Power of Attorney or b -t.t-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.