HomeMy WebLinkAboutMortgage_McKimmy (2) }, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township
1;__ , ty p Year
_ •,-�: FOR DEDUCTION FROM ASSESSED VALUATION FIT- State Form 43709(813110-15) F R F,
• Prescribed by Department of Local Government Finance Jtll J J
INSTRUCTIONS:
File Mark
To be fled in person or by mail. DEC 5 2017 For,filed with:
Filing Date& 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 •- •petty is a County Auditor
located on or before January 5 of the immediately succeeding calendar year. , ralli ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the County Au.1. . -
,;m
where the property is located during the twelve(12)months before Mardi 31 of each yrsiBreeigh 3hJkl-. ., 0 MGR -
See reverse side for additional instructions and qualifications.
di t(wrier or contract buyer on side)
reverse /�-
side)(�
Taxing District Key number t legal description Record number Page number
c7',e- a /o - le) - / e9_ JP/ - DO /. /67 - 0a-4 ao /7 YGP 1LC
Assessed value of real property as of Mortgage 1 Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment dat,current year assessment data,current year date of application / legal or equitable owner?
I405coo ❑ Yes El No
If no,what is his 1 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: Is the ro
p paty in question:Annually Assessed
x Real Properly ❑ Annually Assessed
• Mobile Fbme(IC 61.1-7)
Name of mortgagee or contract seller 7
Address of mortgagee or contract seller(number and sheet city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Ad f assignee(number and street,city,state,a ZIP code)
- 21A-e flh.oe.,/' 3 9 — —
other applicant own
pro g1711-
in any If yes,what county? what Taxing District? -- .+ate amount of deduction on
in Indiana? ❑Yes ❑NO a. -�
• A person is not entitled to this deduction unless the person has a balance on the person's r - dig
recorders office(including any home equity tine of audit that is recorded in the county rec I Dra{ti•CT-N
COUNTY AUDITOF : O••••WG•�•
Deduction approved in the amount of / / ••..
Card N'O. ... l C
20 20 20 20 ' 1
. I _
Signature of County Auditor County - Date(mown,•...,,,
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 t contract buyer of the aforementioned property on date application is filed.
�Signatur owner's lull namee)),,n �,( Date(month,day,Year)
r �t ,,` nu � street };state,and ZIP e) •
I address of applicant(num g,
t/b o Crt t K Dr. ..'S��t.�lam `► U `i g
Person authorized by duly executed of Attorney or by ICI-hi-2-07 Date(month,day,year)
Address of authorized person (number and sheet may,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.