HomeMy WebLinkAboutMortgage_Cullivan (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
G'! FOR DEDUCTION FROM ASSESSED VALUATION?'; State Form 43709(R13 f 10-15)
�-- Presafied by Department of local Government Fnance
File Mart
INSTRUCTIONS: 2 +. ��vntin
To be filed in person or by mail DEC .
Filing Dates 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 the properly' ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. I IN ' •u Recorder
2) Mobile/Manufactured Homes not assessed as Real Pro '" '1l�'i.
Properly Must file with the County Auditor
where the property is located during the twelve(12)mats before Mardi 31 of each year the�'-I13-•r, N- - • •• • -
See reverse side for additional instructions and qualifications.
Appika (owner or contract buyer-see O on reverse side) t
Taxong District r Key number/legal description Record number Page nu ber
(f l ilk- o 6 - I9 - aGo - oo0, 7Y8-o17 J617 Page
Assessed value of fat property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole •
assessment dale,current year assessment date,current year date of application legal or equitable owner?
If no.what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom ❑ Yes El No
tf name on record 5 different than that of applicant indicate below: is the property in question:Annually Assessed
❑ Real Property ❑ AnnuafyAssessed
• Mobile Home(IC 6-11-7)
Name of mortgagee or contract seller
/ At —n e- 76 e-T-i- ,
Address of mortgagee or contract seller(number and street city,state,anigalP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code)
Does applicant own property in any If yes,what county? 1Mmat Taxing Disr� 2 1 `=S sled If yes,state amount of deduction
other ..
in Indiana? ❑Yes 0 N �O J /\a �J-\� No
A person is not entitled to this deduction unless the persons- ^ J�ti \r-� "mess that is recorded in the county -
n;corder'soffice(including any home equity line of tied. ,�p• ' L)- \ for the deduction.
Deduction approved in the amount of. e\--$--.6 o�
20 20 20 C' ,z \6 t I 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 filed.
Sig.= r- yry�,•, 1� f Dare(month,day,year
,!: l l `( bar In / gr�
Ftdl .- ad.1_-,of t hum a d city, aril LP )
6o(0Ce e 390 /� ,� `1—)62
Person authorized by duly executed Power of Attorney or by IC 6-11-12-0.7 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 two and a half years and a fine not to exceed$10,000.
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