HomeMy WebLinkAboutMortgage_Pottorff STATEMENT OF MORTGAGE OR CONTRACT INDEBTE tlf Township Year
A't, FOR DEDUCTION FROM ASSESSED VALUATION F 1 ivy
State Forth 43709(R13/10-15)
"----• Presorted by Department of Local Government Finance
INSTRUCnons: iiov 3 2.0tt- File Mark
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 bed-, ..4. i ..r;
Must be filed or postmarked with the County Auditor or County Recorder of the •-•41 ,,, ..,cr!ne: raedy County Auditor
located on or be fore January 5 of the immediately succeeding calendar year. r-i�111 (�1T( AUDD%�r
2) Mobile/Manufactured Homes not assessed as Real Property:Must file umyA)udrtor of the county County Recorder
where the property is boated during the txehe(12)months before March 1 of each year the deduction is sought
See reverse side far additional instructions and qualifications.
Applicant(own rr, rconn irbower-see;;. ,' I side) .. Record number Page number
T r2�f(uNl �C/pM/Cn Key number
, -j8 O3 cc / 4, l09 oo 8 7 3 3�f
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
atsessment data,current year assessment date,current year date of application legal or equitaVe owner?
❑ Yes ❑ No
If no,what is his/her exact share of interest? R owned with someone other than spouse,indicate with whom
If name on record's different than that of applicant indicate below. Is the property in question:Annually Assessed
(Real Property ❑ AnnuallyAssessed
• Mobile Hone(IC 6-1.1-7)
Name of mortgagee or contract seller
Address ode)
Name of 81 I I. f- Ess f O 4 60
I 0
Address, Drawer NO •
Does app .( 2 9 C) I District? Has on p this deduction been requested If yes,state amount of deduction
in Indiana Card NO. ✓U current year?Mr ❑yes. El No
n Ind ana
.4 person is nor enunea to des 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 or 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.
Signatur- (• 1..he name) ' Date(month,day.year)
>• . f , F. im( I) ,
Full resid,' ,•dress of applicant(number d state,and P code)
2 -h. 0 I G-t•Ls o ri,iC €4n Ti) 876700
Person authorized by duly executed Power of Attorney or by IC 5-1.1-12-0.7 i Date(month,day,yea,)
Address of authorized person (number and street dry,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.