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HomeMy WebLinkAboutMortgage_Lafoe (2) ...tilt STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year 141= -. FOR DEDUCTION FROM ASSESSED VALUATION State Fonn 43709(R13/10-15) S Presabed by Department of Local Government Finance To INSTRUCTIONS: l : F.) RI be e filed in person or by mail. 5 Filing Dates 1) Real Property Must be completed and dated in the calendar year ion whidi the deduction is sought Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is J ❑ County Auditor located on or before January 5 of the immediately succeeding calendar year. �our1 uftecorder 2) Mobde/Manufactured Homes not assessed as Real Properly Must file with the County Auditor of the county where the property is boated during the twelve(12)months before Mardi 31 of each year the deduction is sought See reverse side for additional instructions and qualifications. 1. Applant(amero buyer-seerestricarns on .% / GIBSOfV 0, COUNTY AUDITOR Taxing District number/'s 1- ' n•--- m'/gr � - is —I ; - � i -©0A • Slog -DaF Remd°iO P�I7m! Assessed vahie of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole assessment date,cement year assessment date,anent year date of appteation S_�. 00 l� ❑ Yes e ❑comer?No d no,what is he/her exact share of interest? If arced 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 ❑ Annually Assessed Mobile Hone(IC 6-1.1-7) Name of mortgagee or contract seller Q �I 1 3 Address of mortgagee a contract seller(number and street city,state,aanddI ZIP code) Name of assignee or other comer or holder of mortgage — - Address of assignee(number and street dry,state,and •Does applicant own property in any Kyes,what count Drawer NO V " --- trusted If yes state amount of daftxion other in Indiana? ❑Yes ❑No ❑No A person is not entitled to this deduction unless the Card NO: I ( � debtedness that is recorded in the county recorder's office(ncluding any home equity line of ,basis for the deduction. VVuw1 r nl-V..V.' Deduction approved in the amount of 20 20 20 20 20 20 20 Signature of County Auditor County - Date(month,day,year) I h 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 err/contract buyer of the aforementioned property on date application is filed. Sig ) Ind/gym )1 PA V r� Date(monN�day, /yer'10 .. Full dress t(nurn" , -.:- -' , and ZIP cede) (J d(/ it i , I ... Q.v—e_. � Lt 2 LID Peexecuted , son authorized by duly executed •• � of Attorney or by IC 6-1.1-12-0.7 Date(month,day.year) Address of authorized person (number and street dry,state,and ZIP code) The penalties for penury can include imprisonment up to two and a half years and a fine not to exceed$10,000.