HomeMy WebLinkAboutMortgage_Harris V .y,� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
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FOR DEDUCTION FROM ASSESSED VALUATION
W-- State Form 43709(R13!10-15)
�� " Presaged by Department of Local Government Finance i II)
INSTRUCTIONS: • t -
To be filed in person or by mail. Form fled with.
Ring Dates' 1) Real Properly Must be completed and dated in the calendar year for whirl the deduction is sought DEC 2 0 2117_,
Must be hied or postmarked with the County Auditor or County Recorder of the courtly where the property is County Auditor
located on or before January 5 of the immediately succeeding calendar year ■ •unty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the iI'-•unty , d
where the property is located during the twelve(12)months before March 31 of each year the•.• .- r! %-.agr e;
See reverse side for additional instructions and qualifications. G I BSO N COUNTY AUDITOR
Applicant(owner or contract Wryer-see restrictions to:Averse side)
Taxing District Key number/le9�description Record number Page number
act, - ao -/s - a-oy - 000. o7a _Do .1._ aol7 5OS )-
Assessed value of real as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole •
assessment date,current assessment date,wrmnl year date of application legal or equilahte owner?
I i OOO - ❑ Yes ❑ No
If no,what is his!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 tog property in question:Annually Assessed
IM"Real Property ❑ AnnualyAssessed
• hbblle Home(IC 6-11-7)
Name of mortgagee or canted seller
Address of mortgagee or contract seller(number and street city,state,and ZIP code) RC t1/4)`�Y c:I'
Name of assignee or other owner or holder of mortgage aid I., 0.yih.1 S `(.
Adgnss of assignee(number and street nary,state,and ZIP code) it? -80s--, �O E.-Cr.-Q(1 —
JYJI� NE 15 - 3 - 9 i. 12`1 A- C- l000• oo (k �-, —
Does applicant own property in any If yes,what county? Mat Taxing District? Has this deduction been,w.
inIndiana? ❑Yes ❑No current�n ❑Yes- ❑No
• A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contact indebtedness That is recomeu... dy
recorder's office(including any home equity line of aedit 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 buyer of the aforementioned property on date application is tiled.
\ Signature(amecs full name) Date(month,day,year)
Y\ z --r'r�e.e.--
Full resident address of applicant(number and street city,state,and LP code) c./
4 G9 K7 5 srffL� ifoAO S7 /4 cerre" �N v76 — /
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
‘, Address of authorized person (number and sheet city,state,and ZIP code)
The penalties for perjury can include imprisonment up to My and a half years and a fine not to exceed S10,000. .