HomeMy WebLinkAboutMortgage_Campbell (2) STATEMENT OF MORTGAGE OR CONTRACT Tr.,€a il +r County Township • Year
FOR DEDUCTION FROM ASSESSED VALUATI
i
State forth 43709(813170.15)
•
c-j2- Prescribed by Department of Local Government Finance
I N S T R U C T I O N S: O C T 1 3 2017 File Mark
To be filed in person or by mail. Form filed with:
Filing Dates 1) Real Properly.Must be completed and dated in the calendar year for whist)the ped ght
Must be filed or postmarked with the County Author or County R:.. .. the property is County Auditor
located on or before January 5 of the immediately succeeding cat-r•- -. ��NTY AUDITOR
2) Mobile/Manufactured Homes not assessed as Real Property: - � 'Pt r e'County Auditor of the county County Recorder
where the properly 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.
Ap nt(owneror ^tract buy"(see on reverse side)
Le/1
OP P N 9- ..12,661 fie„
Taws istrict Key number/legal°wciI tb 1 E�'/a%r��s Record number Page number
� r ,5 - - .243 aoin 51/GQo7 / 7 39,6
Assessed value of real property as Mortgage I Contact indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment dale,current year date of application legal or nyIkaMe owner?
70 Coe ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If nacre on record is efferent than that of apprncant,indicate below. Is the property in question:Annually Assessed
u11°"at Property ❑ Annually Assessed
�//(�
Mobile Home(IC 6-1.1-7)
Name Na of mortgagee a contact c;� (��yY
G7JJJJY
Address of mortgagee or contact seller(number and street d0:state,and ZIP code)
Name of assignee or other owner or homer of uu.b,age /r11 M kJ
Address of assignee(number and street,d4 state,and ZIP code)
/Yrn / '// A6
•Does applicant own property in any If yes,what county? What Taxing Distict? action
other county
in Indiana? ❑Yes ❑No /'_3 9/O
A person is not entitled to this deduction unless the person has a balance on the person' 1e county
recorder's office(including any home equity line of credit that is recorded in the county r
COUNTY AUDITOR
Deduction approved in the amount d:
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 filed.
Signature((oormers nil name) Date(month,day,year)
V wfX-
Full resident address appfrent(number and street,city,state,and ZIP code)
k n Pak s-F O kta coy, M./ lin6o
Person authorized by duly executed Power of Attorney orby 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 per)ury can include imprisonment up to two and a hall years and a fine not to exceed$10,000.