HomeMy WebLinkAboutMortgage_Lewis (15) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS �7y�n� 7 , Township Year
*ar't:�} FOR DEDUCTION FROM ASSESSED VALUATION �� p■..,4'� 1111
'
State Form 43709(R13/10-15) �j 4
16 Prescribed by Department of Local Government Finance
INSTRUCTIONS: pEC 13 2011 File Mark
To be fled in person or by mail. - Form filed with:
Filing Dates 1) Real Property Must be completed end dated in the calendar year for which the deduction is so • L
Must be filed or postmarked with the County Audrtor or County Recorder of the county n„- . •-�.t':::r is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. I� -ter'v AUptTOR ❑ County Recorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the all •!.n "(the county
where the property is located during the Awake(12)months before March 31 of=:.• ...' the deduction is sought r�l
See reverse side for additional instructions and quuellificcaations. du”( /� _,cL /r/h/
Applicant(°.. : or�r j .. wryer-aee�e m'rlions one-�.C�.� �, #
Taxing D.•.Vf number I legal description Record number Page number
( - a 4- a 01- 1o1- "3 80-tea(
Assessed wake of real property as of ge!Contraw indebtedness unpaid as of Mortgage I Contract'ra ebtedness unpaid as of Is the applicant the sole
assessment date,arrant year assessment date current year date of application legal or equitable owner?
141 ❑ Yes ❑ No
If no,what is his/her exact sham of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of appri ant,indicate below. Is the property in question:Annually Assessed
❑ Real Property ❑ AnnuallyAssessed
• Mobile Hone(IC 61.1-7)
Name of mortgagee or contact seller
Address of mortgagee or contrail seller(number city,state,and ZIP
Name of assignee or other owner or holder of mortgage ///III���
Address of assignee(number and street city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
county other aPnt for
'n IInnda ma ❑Yes ❑No current year? ❑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(including any home equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction
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 filed.
Signature(owners name) Data(month,day,year)
�r.{0em Lam_ CA-� /��p(�tl( �//t�� 1Lf r a - 3 -)1
FWIc J 1 J 1 I(number shoe;all: . L•T ` w l - `+0 Li 8
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 street 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.