HomeMy WebLinkAboutMortgage_Blevins a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
' - : FOR DEDUCTION FROM ASSESSED VALUATION
State form 43709(R13110-15)
— Prescribed by Department of Local Government Finance Y g J ��Y
INSTRUCTIONS: II
To be filed in person or by mail. Form filed with:
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is soughtn�((`T�
Must be filed or postmarked with the County Auditor or County Recorder of the county where the prep, ii V t I I ILJ County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the/county County Recorder
where the property is located during the twelve(12)months before Mardi 31 ofeach year the r�-rk -�nnw
See reverse side for additional instructions and qualifications. r C_ "pt m i l lJT V 1r)l t f11TO R
Applicant(pe�Grar r-see ' "�on side) d B Q ifikya-
Taring District Ill �^1X1�n J�1�.1 under/legal descn ! `%Jtt Record number a number
(o- oa-sq—o33- ODD, act -019 1 X563
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current Year assessment date,rent year date of appl legal or equitable owner?
(0 Ike ❑ Yes ❑ No
If no,what is his t her exact share of interest? If owned with someone other than win,/44,indicate with whom
If name on record is different than that of appGant,indicate below. Is the property in question:Annually Assessed
❑Real Property ❑ AnnuagyAssessed
• Mobile Forme(IC 6-1.1-7)
Name of mortgagee or contract seller 1^0',_LL'nn
Address of nartgagee or contract seller(number and street ay,state.and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street illy,state,and ZIP D)'U\\'C)' O P26 .1 1
Does applicant own property in any If yes,what county? t 151).3 -equested If yes,state amount of deduction
�iana? ❑yes 0 N Card NO (—'lf 0 N
A person is not entitled to this deduction unless the per indebtedness that is recorded in the county
recorder's office(including any home equity line of ore( . ___..._.- _._..,....iv.a voice)mar is the basis for the deduction.
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 correct and that the applicant is a resident of Indiana and
owner I i-GI buyer of the aforementioned property on date application is filed.
Sig r rue name) Da (month,day,Year)
Fug resi.o �,. t.: andstreet, a ZIP e)a Li q()
Person authorized by duly executed Power of Aitomey or by IC 5-1.1-12 Date(month,day,year)
Address of authorized person (number and street city state,and ZIP code)
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The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.
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