HomeMy WebLinkAboutMortgage_Leible mss^ STATEMENT OF MORTGAGE OR CONTRACT I',I± ! N ounty Township Year
Ef' '' FOR DEDUCTION FROM ASSESSED VALUATI•
�'ff State Form 43709(R13/10-15)
-1 Presaibed by Department of Local Government Finance DEC 12 2017
INSTRUCTIONS: • File Mark
To be filed in person or by malt Fonn filed with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for 1vh4j��I ,,••_•;,).d:7 .• sought
Must be filed or postmarked with the County Auditor or County Recorder 4614 ►ra it . , : freperty is County Auditor
located on or before January 5 of the immediately succeeding Gana, •:. • /❑ County Recorder
2) Mobile/Manufachned Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Appiiran •corer or contract., .see tesbiaronyon reverse side)
Taxing Dr•• / Key number I lerpl desajgbon Record number Page number
ialiniC/I 26119- 03-r-11/./Q . as (- /7 5/ ')
Assessed value of meal property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid 3s of Is the applicant the sole
assessment date,=rent year assessment date,agrentyper date of application legal or equitable owner?
/ 426, 67U ❑ Yes ❑ No
If no.what is his/her exact share of interest? It owned with someone other than spouse,indicate with whom
tf name on record is different than that of applicant,indicate below'. is the om in question:Annually Assessed
. f_7cRe41 Property ❑ AnnualyAssessed
Mobile Home(IC 61.1-7)
Nacre of mortgagee or/ act seller -
t i,( a Address of mortgagee or co tactsr u
Name of assignee or other owner or holder of mortg Le k o\t \ I l (1 7-4
Address of assignee(number and street,city,state,
�
Does applicant own properly m any If yes,what d 0 1 c lun requested If yes,state amount of deduction•
other'm Indiana? ❑Yes ❑No I 0 N
• A person is not entitled to this deduction u'„",,`,,,y,! n 1/�1 c indebtedness that is recorded in the county
recorder's office(including any home equity uH C_ ( c c\c( ` I s the basis for the deduction.
Deduction approved in the amount of. (\-''�,\ \ J
20 20_ ^-`1} I 0 20 20
Signature of County Auditor
\ 1 Date(month,day,year)
I
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 aforementioned property on date application is filed.
Signature(owners tug name) J ,.Q Q�Q Dale(month,day,year)
7� aY({Y /C1 / - la--l7
address of applicant(number and street,city,state,and LP code)
?4 ga S, ,ndee L-n �^er4 Srar>r� _c Al 47iegf8
arson authorized by duty executed Power of Attorney or by IC 61.1-120.7 Date(month,day,year)
Address of authored 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.