HomeMy WebLinkAboutMortgage_Hayes as STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
f",`- t? FOR DEDUCTION FROM ASSESSED VALUATION
Y - �.i... T
° State Form 43709(R13110-15)
Prescribed by Department of Local Government Finance -
INSTRUCTIONS: A • 2011 File Mark
To be filed in person or by mail. QV 1 3 Form filed with: '
Filing Dates 1) Real Property 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 where the prope a is $2 County Auditor
located on or before January 5 of the immediately succeeding calendar year. 11,jtr. _
2) Mobile/Manufactured Homes not assessed as Real Pro • .'�� ,r County Recorder
Properly:Must file with the County Au.;... .:�. - . trtyt .VDI
where the property is located during the twelve(12)months before March 31 of each -:.- ..,..,.:..*CUM i ., t
See reverse side for additional instructions and qualifications. 1
Applicant(ownef or con see rc reverse side)
T Mit Key number I legal description o Record number Page number
\net ntaint> a -/a-78' -.3)5 - oo / . NJ-Oa? Sl .o/ 7 41 416,2
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
assessment dap,current year assessment date,parent year date of application legal or aqui:ahie owner?
/06 3 00 ❑ yes ❑ No
If no,what is his/her exact share of interest? If wined with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: _ I Is the property in question:Annually Assessed
Name of mortgagee amnba contract Drawer NO Net
Address of`ortgageee or� (number and street,aty,state,and ZIP code) / // / /_
Card NO. �TL`f/ l/X�
Name of assignee or other owner or holder of mortgage
to a(-t-1 R- i6(er 3 der
Address of assignee(number and street city,state,and LP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county ,-.., property for
in Indiana? yes ❑No current year? ❑
current 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 recorders 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(mach,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and coned and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
S- a(owners Ml name) Dap(month,day,year)
X A.JmY �CO
Full resident address of applicant(num and sh�ee�t�'state,and ZIP code)n�
x /904/ NS Jain , iatJa1 v J& /7676
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Data(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
The penalties for per)ury can include imprisonment up to two and a half years and a fine not to exceed$10,000.
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