HomeMy WebLinkAboutMortgage_Kiely a-,4, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou •;_ - , • • Year
FOR DEDUCTION FROM ASSESSED VALUATION I ; ' t
State Form 43709(R13110-15) ;'C`
`—' Prescnbed by Department of Local Government Finance
1NSTRUC77ONS: - OCf'�1l�9_LI817
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 which the deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property)Il _ • n Auditor
located on or before January 5 of the immediately succeeding calendar year �JOtPRt
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor ofalMityC GU V - �itlyttorder
where the property is located during the twelve(12)months before Math 31 of each year the deduction is sought
See reverse side for add''• al instructions and qualifications.
Applicant(owner arson.. •.yer restriction on re ) . •
,/ 7 / tl(g�scn /� '•Taxing District / ,y Key�•��- !legal `J 3 /1!1 - 0 G IC-?- l 9a-) Record number
3��t1e�
Assessed value of real property as of
6-
Mortgage I Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the applimr t the sole
assessment date,wheal year assessment date,aurent year date of-p" legal or equitable owner?
❑ Yes ❑ No
If no,what is his/her exact share of interest'? If owned with ne other than spouse,indicate with whom
If name on record is different than that of applicant,indicate bebw Is the property in question:Annually Assessed
U
/1n ❑Real Property ❑ AnnuallyAssessed
t I L Mobile Home(IC 6-1.1-7)
Name of mortgagee or contact seller
Address of mortgagee or contact seller(number and street oily,slate,and ZIP code) -
Name of assignee or other owner or holder of mortgage . (-�rF^V•
Address of assignee(number and street city state,and 2 ViE L LAIR��"' iZ6�
Does applicant own properly in any If yes,what county (_,J-T '`IS 44 I requested If yes,state amount of deduction
other count' n
in Indiana? ❑Yes ❑No 171.•1.• 3 625 s ❑No
A person is not entitled th
ed to this deduction unless e) 1 f indebtedness that is recorded in the county
recorder's office(including any home equity line of c ,the basis for the deduction
Deduction approved in the amount or
20 20 20 20 20_ 20 20
Signature of County Auditor County Date(month,day,year)
I/We certify under the penalty of per)ury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
contract buyer of the aforeme•:• property on date application is filed. .
Sig re( s hill name) ( l/ Date(man day,yea
ufl r • a3 . 1 t(num(>er o d l ' nil ZIP e) �� �1 /� ci 7&2 D
Person authorized by duty executed Power of Atomey or by IC 6-1.1-1` Pt's-pi!_'_1 Cwt Ly'l Date(month,day,yew)
.. _ _ _ _
_.
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.