HomeMy WebLinkAboutMortgage_Cox (3) STATEMENT OF MORTGAGE OR CONTRACT INDEBT
fjs'?: .w Township Year
FOR DEDUCTION FROM ASSESSED VALUATION �pjel6,p !
State Fonn 43709(R73/,0.,5) �J I
�-- Presafied by Department of Local Government Finance
INSTRUCTIONS: 0 C T 14 201? File Mark
To be Filed in person or by mail. Form filed with:
Filing Dates: 1) Real Properly Must be completed and dated h the calendar year for which di d action i so t
Must be filed orposbnarked with the County Auditor or County RReeccoorrd�earr ,,((hhe property is to County Auditor
located on or before January 5 of the immediately succeeding cal nddYWalON C p[l
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the County Atiiditc0Vaid'g7Rnly 0 Courtly Recorder
where the property is located during the twelve(12)months before March 31 of each year the reduction is sought
See reverse side for additional instructions and qualifications.
Applicant(owner or Contract buyer-see on reverse side)
ClG7nirn,y
Tatting .�.%- Key -.3 o 3 a� io/ 00 9 Record number
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contrail indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment dale,current year date of application legal or equitade owner?
n 3 50° ❑ Yes ❑ No
If no,what is S I her exact share of interest? If owned with someone other than spouse.indicate with whom
If name on record is drfferent than that of applicant,indicate below s��thg!p�ro�perty in question:Annually Assessed
N"`°'Property ❑ AnnuallyAssessed
• Mobile Hone(IC 6-1.1-7)
Name of mortgagee or oonfraceller
Address of mortgagee or contract seller(number and sleet,city,slate,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,dry,state,and ZIP code) C..(--V... C�
T^tivYNc1'C � —•
Does applicant own property in any If yes,what county? What Taxing District? Has this c qu„v r-��-V\ �OD-rG>-1_ NC'
—
in lnra" na?y ❑Yes ❑No rent ye pp .0O '\V'V_' V1
A person is not entitled to this deduction unless the person has a balance on the person's martga& C
recorder's office(including any home equity line of credit that is recorded in the county recorder's u 'DO \'l _.y)-Qo G
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 coned and that the applicant is a resident of Indiana and
owner!contract buyer of the aforementioned property on date application is filed.
•Sgnaaree((o owner's e) Date(month,day,year)
Full resident address of apppppliliccant(number and sfreeet,dry.state.anfas/a'd/,ziV X74 Person N as aJ t°du-th 4,-ezem Ja t,. y/r.L 3 9 Data(month,day,Year)
Address of authorized person (number and street city,state,and ZIP code)
The penalties for penury can include imprisonment up to two and a half years and a fine not to exceed$10,000.