HomeMy WebLinkAboutMortgage_Riley (3) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
F:"._r_ County Township Year
`'`l,, FOR DEDUCTION FROM ASSESSED VALUATION IL
Stater Form 43709(R13/10.15)
Prescribed by Department of Local Government Finance
INSTRUC77ONS:
File Mark
To be filed in person or by mail NOV 1 3 2017 Form filedwtth:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is song t
Must be filed or postmarked witty the County Auditor or County Recorder of the county where the property is • County Auditor
boated on or before January 5 of the immediately succeeding calendar year // .i ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Au•'••7' �a::d"'7►•
where the property is boated during the twelve(12)months before Math 31 of each069gs k p's ' .•••,-. D tOR
See reverse side for additional instructions and qualifications.
Applicant(owner or contact buyer-see restrictions on reverse
-ne1A--1---11-424-2/
Taring District eirumier t(egal description Record number Page number
0al-4,.S 26 -) It-/8 -- /0y - 000. 7 7 9 -00 7 all 3u to 7
Assessed value of real as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of il
s the appli ant the sole
assesvrem date,caurent asses ment date,ement year date of applicationnn egal or equitaNe owner?
If no,what is ids I her exact share of interest? If owned with someone other than spouse, with whom Yes ❑ No
if name on record is different than that of appraanl,indicate below is the property in question:Annually Assessed
❑Real Property ❑ AnnuallyAssessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller A
Address of mortgagee or contract seller(number and sl et,city,state,and ZIP code)
Name of assignee or other owner or holler of riu•1gege
Add of assignee(number and sheet city,state,and ZIP code) Ch orzk G Q r.F,y. ,C S h'i c\- \C�
•
Pr sF_ Ni Is - 1 - s • 5 II- /-t S
Does applicant own property in any If yes,what county? What Taxing District? Has this ao 11 -34(o 7 \ S". \7 S.o 0
in Indiana? ❑Yes ❑No current year?
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or t- MTh- Cl
recorder's office(including any home equity tine 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 I We certify under the penalty of perjury that the above and foreg•4-•• information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer f th aforemention pro on d.r- non is filed.
Signature(owners fug • /p/Gr/(y •, Date(month,day,year)41
AtWI resident address of �t(number state.and P code)
335' MI c__ 1 &f N1a 1/77/ Zff/ 4/7b60
Person authorized by duly exalted Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day.year)
Address of authorized person (number and sweet city,state,and ZIP code)
The penalties for perjury can include imprisonment up to Iwo and a half years and a fine not to exceed$10,000.