HomeMy WebLinkAboutMortgage_Robertson o'7_, STATEMENT OF MORTGAGE OR CONTRACT IN �IE. i7 ntL I Township I Year
A FOR DEDUCTION FROM ASSESSED VALUATION
ti ft State Form 43709(R13 1 10-15)
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Prescribed by Department of Local Government Finance V 2 2 19
INSTRUCTIONS: File Mark
To be filed in person or by mail. 4 al Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which thi471T -: M�:•hhtt.�T�TnrRe�
Must be filed or postmarked with the County Auditor or County Recorder of th' • • •rg liepopertyis ❑ County Auditor
located on or before January 5 of the immediately succeeding oaten $5O ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must r etY with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sou ht.
-' everse side for additional instr6ctions- • qualifications.
App ca (o -r or contract h er-see restricbo • reverse side)
r �. �. • ►.._ � _ V a Ste . 1 u.
Tax' District Key nu ber/legal de: ption Record number Page number
Vako1CG AL) - 1I - 15 - Am - cs-2 . i -c_ `1- io1� - 9(0
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness u(999Appaaa/))d�as of Is the applicant the sole
assessment date.current year assessment date.current year date o tia sa W legal or uiable owner?
I//l �]J' �y��,`,]]{{ l'j(a1 Yes ❑ No
If no,what is his I her exact share of interest? I If owned with someone ether than spouse.indicate with whom °\\
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
AReal Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name ortgagee or contract seller
Q rm awl ( �nc ►' (111p, 1 a c9-1 p
Addres 7ngagee or c nzseller(n17 rand streelt,,ty, a and ZIP code) / ,
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any If yes,what county? Nfiat Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes 0 N current year? ❑Yes 0 N
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 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 aforementioned property on date application is filed.
Si er's full na • Dati(month.d ' year) r�
Fu resident addr es of a pica be and sir-1 city.state.and Z. code) (� ��-({"�{{/ (�
1 ' \eet` IQ nr. 'crc1 �-�-ctt tN I ' `'-0
Person authorized by dui executed Power of Attorney or IC 6-1.1-12-0.7 y y y by Date(non;h,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.