HomeMy WebLinkAboutMortgage_Banks ,<a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
;l=- ` FOR DEDUCTION FROM ASSESSED VALUATION
: '' State Form 43709(R13110-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: • IF
To JIt"a`
be filed in person or by mail. g
Filing Oaten 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 is O C Cg my Auditor
located on or before January 5 of the immediately succeeding calendar year °P?(y Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the properly is located during the twelve(12)months befom March 31 of each year the dedudfon is soughtl
See reverse side for additional instructions and qualifications. JJ4znr' rr3
Apphnnt(owner.{contractbyer-
4,74 - _
Taring District U /legal description Records r Page inD I
a11 3-R-30D 'OD 1. 013 - 00(0
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Cont-act indebtedness unpaid as of Is the applicant the sole
assessment date,aurent year assessment date,current year
data of application legal or equitable owner?
1 4b1 nal ❑ 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 retard is different than that of applicant,indicate below Is the property in question:Annually Assessed
❑ Real Property ❑ AnnuallyAssessed
Mobile)time(IC 6-1.1-7)
Name of mortgagee or contract seller 1/ V
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code) (�� y1-
Does applicant awn property in any If yes,what coo V'Y' `-^'-�"�5 �r lS\ t e . been requested If yes,state amount of deduction
other county 1
in Indiana? ❑Yes 0 N tar�kS Tc� Fr:C�ur.\ Clot gajf]Yes, 0 N
A re�r'ssotficee(md ing any home unless
line) ,� \3'a t S 6 1 .o v \o-13-h Mt is the
basis for the deduction.wed in the county
a0 \--1 -`0 01
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 correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforemen• ned property on date application is filed.
Si re(owner's r name Dale(month,day,year)
a I0-30- 1
F .t, ., applicant(number and street,city,state.and ZIP code)
( 0 :Is 4 tE gas s 003.8. a,y?. ecoo
Person authorized by duly executed Power of Attorney or by 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 perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.