HomeMy WebLinkAboutMortgage_Straw (2) �-s� STATEMENT OF MORTGAGE OR CONTRACT IN !TrS$' ri
�� - Township Year
FOR DEDUCTION FROM ASSESSED VALUATION Ig1J
State Fomn 43709(R13/10.15)
�--- Prescribed by Department of Local Government Finance
INSTRUCTIONS: JAN 1 8 2017 File Math
To be filed in person or by mail. - Form filed with:
Filing Dates: 1) Real Properly.Must be completed and dated in the calendar year fix which ppeel 7"
Must be filed or postmarked with the County Author or County Recorder of did properly is at-1.County Auditor .
located on or before January 5 of the immediate&sucoeedingcaIen9w,iN COUNTY AUDITOR
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the 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 edditional instructions and qualifications.
Applicant(owner contras buyer-see iesrtttions on )
Taxing Key number/legal description Record number Page number
Z „ - 7-�a - aoz{ / a07S ao�8 7a
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/ ind ness unpaid as of Is the applicant the sole
assessment date,currerd year assessment date,current year date of application legal or equitable owner?
''4/e)0 ❑ Yes ❑ No
If rno,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is efferent than that of applicant,indicate below: Ig pro�perty in question:Annually Assessed
eal Property ❑ Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 5/.5
Address of mortgagee or contract seller(number and street dry,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 corn property in any If yes,what county? Mat Taxing District? Has this deduction been requested If yes,state amount of deduction
ry a�t ❑�iana? ❑Yes ❑No current year? 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
reoorders office(including any home equity fine 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 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!contract buyer of the aforementioned property on date application is filed.
Signatu(e(owners rug name) Date( .uric,da yea
mot— / R-
Full resideptgtl of apglcant(number and sr city,state,and ZIP 76
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 dry,state,and ZIP rode)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.