HomeMy WebLinkAboutMortgage_Nixon (7) STATEMENT OF MORTGAGE OR CONT ! 1 'E 'l �.S County Township Year
FOR DEDUCTION FROM ASSESSED VA
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'. State Form 43709(R13/10-15)
`-- Prescribed by Department of Local Government Finance
OCT i 1 2017
File Mark
INSTRUCTIONS: •
To be filed in person or by malt Form filed with:
Filing Oates 1) Real Property:Must be completed and dated in the calendar ,r for-,gl�!1�/%�•-•(ratan is sought
Must be filed or postmarked with the County Auditor or Coun •• - A l url t where the property is ❑ County Auditor
located on or before January 5 of the immediatef su�gg®bg jOkH dY. DIIUIt ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the count
Were 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(owner or contract buyer-see restrictions on reverse side}- •
J %¢� n1_) /Y) 9-a C 7p/41.rd.4-19 F .1/ a l
T %ZU I I Key number 3002 -odd, va7oa ,7 Record number Page s 9
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,anent year date of application legal or equitable owner?
/00 000 ❑ yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whore
If name on recut'is different than that of app5ant,indicate below Is the property in question:Annually Assessed
PrFeal Property ❑ MnuallyAssessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contact seller —
Address of mortgagee or contact seller(number and street city,state,and ZIP code) /
Name of assignee or other owner or holder of u.atguge V O( °Cila
Drawer NO........
Address of assignee(number and street city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Card n �
other county O• lucbon
in Indiana? ❑yes ❑No ta_ 1(-1
A person is not entitled to this deduction unless the person has a balance on the person_ 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 dppu.ed in the aimunt 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 filed.
Signature(owners full name) Date(month,day,year)
' F ad ess of app6Fant(number and steep city.state,and ZIP code)
l/ay N. Ma.4 Ventl Tri4CCf.n =fJ `(7670
Person authorized by duly executed Power of Attorney or by IC L1.1-12-0.7 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.