HomeMy WebLinkAboutMortgage_Obert (2) ' x STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
° State Form 43709(R13110-15) it g
Prescribed by Department of Local Government Finance 1
INSTRUCTIONS: File Mark
lb be filed in person or by marl. Form filed nth:
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the S&A r p�empgrpt
Must be filed or postmarked with the County Auditor or County Recorder of the county wherr;"drbrproperty is ❑ County Auditor
located on or before January 5 of the immediately suCeeeding calendar year ❑ County Recorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with un rfit unty
where the property is located during the twelve(12)months before Ma3f 0 udion is sought
See reverse side for additional instructions and qualifications. 5 N CO COUNjy Al fn(TOf2
Applicant(owr(er or contract&Ter- fie rse syq /
Taxing District '. Key number I legal desa cation/fie. •/_t-/1'y- Record number Page ycr
. &/7- -i 3-02606 9 77,1/ 6'025 . (A6(se a ._
Assessed value of real p as of ge I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid f Is the applicant the sole
assessment date,current year assessment tdCdate ameN r date of application legal or equitable owner?
jv3 ❑ Yes ❑ No
If no,what is his l her exact share of interest? If owned with someone other than spouse,indicate with when
If name on record is differer than that of applicant,indicate below: Is the property in question:Annually Assessed
❑Real Property ❑ AnnuafyAssessed
Mobile Home(IC 61.1-7)
Name of mortgagee or contelier
Address of mortgagee or contract seller(number and sheet city,state,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 a his deduction been requested If yes,state amount of deduction
imnindiana?ry ❑Yes E ntnt year? ❑Yes. 0 No
• A person is not entitled to this Drawer O... b.'..I.�--;.. T4age or contract indebtedness that is recorded in the county
recorders office(including ar, /V'.-. er's office)that is the basis for the deduction.
Deduction approved in the ama Card NO. H Q /l
20 2 ��11 20 20 20
Signature of County Auditor - t.ounry - 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 rementioned property on date application is filed.
Signatur '/E� Date Urrzndh,day,year)
•
Fug • address of t(num street city,state,and Z/Pcode) i(7�/L0f 7
,s3 /te: /6r Fr. n-*re-t ./+/ � 7of S�
erson authorized by duly Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
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. - - 2