HomeMy WebLinkAboutMortgage_Miller (24) ss STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
A.,4:- State Form 43709(R13110-15) gg 4 -per
`i- Prescribed by Department of Local Government Finance F I 11_r D
INSTRUCTIONS: _ attk�'1.
To be filed in person or by mail. Form filed with:
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought DEC 2 7(�1
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is `aOUnty Auditor
located on or before January 5 of the immediately succeeding calendar year"
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the cou � ❑ Cos- Recorder
where the property is located during the twelve(12)months before Hewitt 31 of each year the deduction is sm 'r"'Y^" ',
See reverse side for additional instructions and qualifications. G I BSON COI Ir.- i ./ r.,:- .t
Appfia , .i contaabuyer- 4 �sM/ej
0 �7 / U�
T.. `r'-i • Key�/ disc iption number number
�/ • xo-//%03-iao OD/ o OS-a 2 ( , / 7 ,;/7 ,
a Mortgage I Contact indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the applicant the sole
acoccment date,aimed year assessment date,current year date of application n� legal or equitable amer?
VV dam{,// / ❑ Yes ❑ No
tf no,what is his/her exact share of interest? If owned with someone other clxvrc(,indicate with whom
If name on record is different than that of applicant indicate below. ReRea property in question:Annually Assessed
2 lPmperty ❑ Af lnlraliy Assessed
Mobile Home(IC 6-1.1-7)
Nam of mortgagee or contras seller
Address of mortgagee or contact seller(number a t city,state,and ZIP code)
Nam of assignee or•. = yy or hod mortgage
♦ ' a. t0 �� 3-3-ia 19x0719(,
Address of assignee(num.-id street dry,state,and- P code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested It yes,state amount of deduction
mhindiaa7H ❑Yes 0 N current r7? ❑Yes. 0 No
• A person is not entitled to this deduction unless the person has a balance on the —_'-^^"^....w.e.rro 0 rnnr:c ramified in the coon
recorder's office indudi any home P' -•----f---- -- county
f rmJ Y equity line of credit that is recorded in the cot
COUNTY Al'
Deduction approved in the amount of:
20 20 20 20 )
Signature of County Auditor G (
- 5077
I/We certify under the penalty of perjury that the above and foregoing informat '✓ b5 diana and
owner/contract buyer of the aforementioned property on date application is file
Signature(owners fun name) .
ti /h 74--4-4---
F resident address of applicant(number and sweet city,state,and ZIP code)
it 70/ 5 19610 I,✓ 1),..t, ',Air. rtt1 I-1 76607 S
Person authorized by duly executed Power of Adomey or byte 6-1.1-12-0.7
Address of authorized person (number and street city,state,and ZIP code)
The penalties for perjury can indude imprisonment up to Iwo and a half years and a fine not to exceed$10,000.