HomeMy WebLinkAboutMortgage_Delong STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' ' ` FOR DEDUCTION FROM ASSESSED VA�L � County Township Year
}'^ State Form 43709(R13/10-15)
I
�--' Prescribed by Department of Local Government Rrt
INSTRUCTIONS: File Mark
To be filed in person or by mail DEC 2 8 2017 l�r r• Form filed with:
Filing Dates 1) Real Property:Must be completed and dated in the calendar year for which the dedud.aFJ:s&r*t 20
Must be filed or postmarked with the County Auditor or County R- r.. ,.: •• where the props is ti3County Auditor
located on or before January 5 of the immediately s k -�L jr:T'V�` - ,/ ❑ County Recorder
2) ebra�Ure Manufactured�bae Homes the twelve Real •y•qy:�_Id�c,'f , Aj .ii: trap ti/,r yi "sought
See reverse side s and quaffications. = •N COUNTY AUDITOR
Applicant Onvner- - ,� r --- •,• • on /���stde)
Ay
Taxing D" number//Iegaf desrnPihorh Record n r Page number
,xn.,, p a (fort;-1 -/.7 - 0 y -c7 .786 0 1 • 5SlR
value of real of ge/ indebtedness unpaid as of Mort gage/Contract indebtedness id as of Is the applicant the sole
assessment date,currerd year assessment date,current year data of application legal or equitable owner?
7 7 crci ❑ 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 the property in question:Annually Assessed
Property ❑ Annua yb ss 61.1-7)
Name of\�N con-
ontract n n
sot
Address of mortgagee or seller number and aabeet ay,,state,and ZIP 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? What Taxing District? Iias this deduction been requested If yes,state amount of deduction
other coolly cu�nyimiMan ? ❑Yes El No rent ear? ❑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 recorded in the county
recorder's office(including any home equity tine 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 ot.
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 I contract buyer of the aforementioned property on date application is filed.
Signature tOUmatetu#earne) Date(womb,day,year)
Full reritent3ddres of applicant( ber and street,dry ,and ZIP code)
in IP 9766c
• Person authorized by duly executed Power of Attorney or by IC e-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street oily,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. .