HomeMy WebLinkAboutMortgage_Bolin (3) . STATEMENT FOR DEDUCTION OF MFROM ORTGAGE OR ASSESSED CONTRACT VALUATION INDEBTEDNESS County I Township Year
FILE!J
State forth 437o9(R13110-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: OCT 30 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 which the deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county the p County Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with th editor gfjhtwcoulplTO R
whem the property is located during the twelve(12)months before March 31 of eft year�the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant( or oonpac -see restrctions side)
Tax;pro ° 1cJ oP ov
� ���� Key number I description Record number Page number
Ct!�Xt7 2 6-/_? / ? /G/ ao/. 77(0 oil K 0301 3 o 0
Assessed value y� as of age I Co indebtedness unpaid as a .�Mortgage/Contract indebtedness unpaid as of�Is the applicant We sole
assessment 599
a application legal or equitable owner?
❑ 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 record is different than that of applicant,indicate belay. Is the property in question:Annually Assessed
p:Real Property ❑ AnnuallyAssessed
Mobile Horne(IC 6-11-7)
Name of mortgagee or contract seller _
Address of mortgagee or contract seller(number and street city,state,and ZIP code) O 0 q
01-° I1 "
Name of assignee or other owner or holder of mortgage ........
D1':1\YCC 1\O ...
Address of assignee(number and street city,state,and VP code) .......
Doer couoes own property in any If yes,what county? What Taxing District?
in Indiana? ❑Yes ❑No auientyear7 ❑Yes. ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)that 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 - Dare(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 aforementioned property on date application is filed.
Sig - ownersJf{r�/p�na(me)e)/1 at?
Date(month,day,year)
Lest WI resident a0 ss ci appd(ranl(ndm6er and s�d state,and code)
yo �,��r�7tX mee4.12,v
Person adthorized by duty executed Parer oMWmey or by IC 6-1.1-12-0.7 Data(month,day,year)
Address of authorized person (number and sheet any,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.