HomeMy WebLinkAboutMortgage_Donnell (3) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
r -1 FOR DEDUCTION FROM ASSESSED VALUATION•
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Slate Forth 43709 Department 1Prescribed )Prescribed by Department of Local Government Finance : : I a INSTRUCTIONS:
`, , de Mark •
lb be flied in person or by mail. Form filed with:
Filing Dates 1) Real Properly.Must be completed and dated in the calendar year for which the deduction sQu ]
Must be fled or postmarked with the County Auditor or County Recorder of the county whpk .ibe��§ County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of th co County Recorder
where the property is located during the twelve(12)months before March 31 of each year the u .• ght
See reverse side additional instructions and qualifications.
Applicant(owner trail I -see rysase side) GItiSO'4 '-'s - v AUDITOR
CIAO-try
Tam� � Key number Pilch Record number Page nu r
Assessed value of reel property as of Mortgag /Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appliant the sole
assessment date,current year �dlata,cur�rlera year date of app i ation legal w equitable owneR
62 9 a 9a fa° ❑ Yes ❑ No
If no,what is his I her exact share of inuse5t? If owned with someone other than spouse,indicate with whom
If name on record is different than that of appfiant,'exlicate below- Is the property in question:Annually Assessed
S Real Property ❑ Annually Assessed
• Mobile Horne(IC 6-11-7)
Name of mortgagee a contract seller n /r/ >? I
Address of mortgagee or contract seder(number and street Ciily,state,and ZIP code) (+ L[/ .
Name of assignee or other owner or tender of mortgage
Address of assignee(number and street dry;state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has guested if yes,state amount a deduction
in Indiana? ❑Yes ❑No xC r]No
• A person is not mated to this deduction unless the person has a balance on the pr
(� redness that is recorded in the county
recorders office(including any home equity line of credit that is recorded in the- J \ 's for the deduction.
O P n'
Deduction approved in the amount of - -S.5) \'?-
20 20 20 ' - o — 20 2°-
a \ Co
Signature of.7. . Auditor ' _ - _ L4� 6 q�' Date(month,dw,1^ea>)e7
I/We certify under the penalty of perjury that th:CM-c•• fr.. (-. e true and correct and that the applicant is a resident of Indiana and
owner t contract buyer o the aforementioned property on date a{., a.
igzQtQ name)�pp (number and street city. and ZIP code)
N V
Person authorized by duly executed Power of Attomey or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street dty,state;and ZIP code)
The penalties for perjury can include imprisonment up to My and a half years and a fine not to exceed$10,000.
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