HomeMy WebLinkAboutMortgage_Mizeur (4) a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS it+ �j, Tdv nship Year
, , FOR DEDUCTION FROM ASSESSED VALUATION 11Vr111
-, State Fonn 43709(R13/10-15)
INSTRUCTIONS: by Department of Local Government Finance �OV 2 o i-\- M•
To be filed in person or by mail. .i �led with:
Filing Oates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is snug . • lisarl1' OSt
Must be filed or postmarked with the County Auditor or County Recorder of the county where the 4..;;:• r ptU� County Auditor
located on or before January 5 of the immediately succeeding calendar year GOV ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County A Me county
where the property is located during the twelve(12)months before Mardi 31 of each year th dudk,n is sought
See reverse side for additional instructions and qualifications.
Applicant ory con buyer f res6iciro'rspn re`ersd fide) \ . Record T a� �T ati��/L/-M/ Oren o 75 ("a 7 ad number h/7.5/
Assessed value of real ptiSperty as of Mortgage I Contract indebtedness unpaid as of Mortgage Contact indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,cement year data of application legal or equitable awned.?
/9 Via) ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: 1 Is the property in question:Annually Assessed
Name of mortgagee or contract seller , lam` \l 1 t Ze i7�V' V i,.,-n
CL.� V) 1cK- F'.
CO ddress of mortgagee or contract seller(number and street city,state,and ZIP code) S /3 c�-� 1� I,
� .
Name of assignee or otherowrrer or holder of mortgage DA) l l l S' I \(l 1e50O.00
Address of assignee(number and street cry,state,and ZIP code) l
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 in Indiana? ❑Yes ❑No aaiirrent fir?lot ❑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 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/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 t contract buyer of the aforementioned property on date application is filed.
Signature e) Date(month,day,year)
- -, ii- :&a -/7
utl ii address/ capp5cqgt(number and " ,stain, nd e� �7 9 76 7d
Person authorized`by duty Cexecutedr0 d Power of Attorney or by IC 6-11-12-0.7 •`/lY"T T 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.