HomeMy WebLinkAboutMortgage_Dellinger STATEMENT
EDUC Ill OF MORTGAGE S ED ALUAT INDEBTEDNESS Township Year
'��� FOR DEDUCTION FROM ASSESSED VALUATION �I
State Form 43709(R131 10-15)
�- Prescribed by Department of Local Government Finance
INSTRUCTIONS: NOV 2 71017 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 soug .
Must be filed or poslmarhed with the County Auditor or County Recorder of the county if-re r�--'r71'y2 is County Auditor
located on or befom January 5 of the immediately suooeediig calendar year. •� inUD
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with th= AUDITOR County Recorder
where the property is located d •.e Mil is sou
acing the twelve(12)months before March 31 o/=-%�year deduction is sought
See reverse side for additional instructions and qualifications.
Applicant(own or contract buyer-se' on reverse side)
Mt )
Taxing D Key number/legal description Record number Page number
(:p / is�iati �/ l�S 7 I 11 YgY7 •
Assessed value of real property of Mortgage!Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
f312€&7) ❑ yes El No
If no,what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom
tt name on record is different than that of applicant,indicate below. Is the properly in question:Annually Assessed
. eal Property ❑ AnnuafyAssessed
J" Mobile Home(1C 6-1.1-7)
Name of mortgagee a contract seller —
eCt T F-C 2-I
Address of rmrtgagee or contract seller(number r-7^/�1
Name of assignee or other owner or troller of me Drawer NO /U�' rrr���I
Address of assignee(number and street,city,sta 1 �1 4 .l
Card NO. 1 1 4 t
Does applicant own property in any If yes,wilt een requested If yes,state amount of deduction
in Indiana? ❑Yes ❑No 1 I turieni yeah U 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(inducting any home equity line of coedit that is recorded in the county recorder's office)that is the basis for the deducton.
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 correct and that the applicant is a resident of Indiana and
owner!contract buyeerrr1the afore h-ntioned property on date application is filed. ___
ti8nature�y/�y /`//?'P"" Dale(marts.day.YaaO
'1—.11 address of a 'num.,..... ///.:9-2/2 O 1,
•sheet city,stare,and ZIP code)
on authorized by duty executed - 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 per)ury can intrude imprisonment up to two and a half years and a fine not to exceed$10,000. .