HomeMy WebLinkAboutMortgage_Payne STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coe Township Year
FOR DEDUCTION FROM ASSESSED VALUATION F I 1
:- State Form 43709(R13/10-15) J
C— Presalbed by Department of Local Government Finance
INSTRUCTIONS: NOV 6 2017 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 the deduction is sought i
Must be filed orposbnarked with the County Auditor or County Recorder of the county v.* - thepp Js [ County Auditor
located on or before January 5 of the immediately succeeding calendar year. yJ � . .. -r RD County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the Clp br(�(difprof the iraunty
where the property is located during the twelve(12)months before March 31 of eadfWart le deduction is sought
See reverse side for additional instructions and qualifications.
Appk2nt(owner or
Ta�mg �,c on--Kbuyer restrictions on reverse
Key rtu I legal descdplon a
Q .
Recall number Page number
a in— ap -0R" . r0 czt 9 7/ cry / ,o f 3 FS 7
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,c uwdyear assessment date,current year date of application' legal or equitable owner?
75a o ❑ yes ❑ No
If in what is his/her exact share of interest? If owned with someone other than space,indicate with whom
If name on record is&decent than that of applicant indicate belay. ss�I the property in question:Annually Assessed
Mobile Home(IC 6-1.1-7)
•
Name of mortgagee or contract seller /i/
'7,
Address of mortgagee or contract seller(number and sheet city,state,and ZIP code) —
Ner
Name of assignee or other owner or holder of mortgage 1 S t�2" QQ#
—
Address of assignee(number and street city,state,and ZIP code) Q,o\fie'
0U
other county applicant own property in any If yes,what county? What Taxing District? .3, \-1:3 1�"� \ - O.— (3 1
in Indiana? ❑Yes ❑No (n 0S-1
A person is not entitled to this deduction unless the person has a balance on the person a0\3— _..,,,aped in the county
recorder's office(including any home equity tine of credit that is recorded in the county re ....1 rrte deduc ion.
COUNTY AUDROF
Deduction approved in the amount of:
20 20_ 20 20 20 20 20
Signature of County Auditor County - Date(month,day,year)
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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 e aforementioned property on date application is filed.
r .r ) Date(month,day,year)
WI resident ado,— of applicant(number and street city,state,and ZIP code)
670ts. t( S 0 . -Far- 7 pcncA , -TN 9761/4r
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.