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HomeMy WebLinkAboutMortgage_Gomez (2) ax STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year ift4 gg,, FOR DEDUCTION FROM ASSESSED VALUATION State Form 43709(R131 70.75) �— Prescribed by Department of Local Government Finance INSTRUCTIONS: FleMa .t lb be fled in person or by mail. I gm -k-• i•,1 Filing Dates: 1) Real property Must be completed and dated in the calendar year for which the deduction is sought Must be Med orposbnartced with the County Auditor or County Recorder of the county where the property •unty Auditor located on or before January 5 of the immediately succeeding calendar year. . ty7Recorder 2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county D C�1 cu where the property is located during the twelve(12)months before March 31 of each year the deduction is sought See reverse side for additional instructions and qualifications. Applicant(owner o�pacr buyer-see an hewer ) C tC � c0 h r,t1UNTY AUDITOR Taxing District yq number/ dasa;ption lJ n e number air, (Kilo - 303 booszto bola l ir` ya i Assessed value of real property as of 1 Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole assessment dare,current year I assessment dale,current year date�icatron legal or equitable owneR ❑ Yes ❑ No If no.what is his/her met share of interest? tl owned with someone other than spouse.bmdrate with whom • If name on record is different than that of applicant,indicate below- Is the property in question:Annually Assessed . ❑ Real Property ❑ AnnuallyAssessed Mobile Home(1C 6-t1-7) Name of mortgagee or contract seller /, d 1 Le Address of mortgagee or contract seller(number and street city st ate,and ZIP code) Name of assignee or other owner or holder of mortgage • Address of assignee(number and street city,state, Does applicant apppplic nt awn properly in any N yes,what c • it1 C l_e_4 r` Sob_ I seen requested If yes,state amount of deduction in Indiana? ❑Yes 0 N �ahK )S Yes. ❑No • A person is not entitled to this deduction wiles 0 Cl -s R)--1 tract indebtedness that is recanted in the county recorders office(mduding any home equity lit at is the basis for the deduction. Z ') 1 \DOS \a- 1:A— k1 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 t contract buyer of the aforementioned property on date application is filed. ar�rre s full nor �I r(��Vy 0Q Date(month,day,year) • �F�ull`( � Oad t(number-and dty.state ZIP wde) © ( /I „ LI %& Person authorized duly executed err of Attorney or by IC 6-1.1-12-0.7 (�t�„-t///'p”, 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.