HomeMy WebLinkAboutMortgage_Bottom ,,, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
•a'`` lt FOR DEDUCTION FROM ASSESSED VALUATIO
State Form 43709(R13 110-15)
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Prescnbed by DepartneM of Local Government Finance
INSTRUCTIONS: DEC 2 S 2017 • File Mark
To be filed in person or by mail. I r/' Form filed with:
Filing Dates- 1) Real Property.Must be completed and dated in the calendar year for wh' a deduction i sought
Must be filed or postmarked with the County Auditor or County Recorder tl1'�property is ❑ County Auditor
located on or before January 5 of the irmnediately strcoeedirg calendar
2) Mobile/Manufactured Homes not assessed as Real Property.Md4@soimanD Matt SI4BI'p(X(li county ❑ County Recorder
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for adgaio0al instructions and qualifications.
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T • Key .> legal description Record number Page number
—/ ? J -/03 boa Sy/•�� , 10/1< 7
Assessed value of real property as of Mortgage!Contract indebtedness unpaid as of Mortgage!Contract indebtedness unpaid as of Is the applicant the sole
assessment dap,current year asses srrrnt m year date of application legal or equitable owner?
�/ ❑ Yes ❑ No
If no,what is his I 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
❑ Real Property ❑ AnnuallyAssessed
• (1C Nbb C
Name of mortgagee d seller de Hone
Address of mortgagee o seller(num dry,state, nil ZIP axi
Name of assignee or other owner or holder 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 this deduction been requested If yes,state amount of deduction
other county on e ❑inindiana? ❑Yes ❑No ant 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(nduding 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 ot.
20 20_ 20 20 20 20 20
SignaIure of County Auditor County • Date(month,day,year)
I 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( )� Date(month,day,year)
•
Full resident adtlress` rr6 (number and aty,slap e�• 76y8
MOO CO4p/1 �C/L
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 perjruy can include imprisonment up to two and a half years and a fine not to exceed$10,000.