HomeMy WebLinkAboutMortgage_Hix STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
kt -=:= FOR DEDUCTION FROM ASSESSED VALUATION
�' State Fonn 43709(R13/10-15)
Presaibed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduct ion is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelie(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Appbcant(ovarer trait�resvctiorr51on reSe s pe .
I I� l/(�J/I`• )VAS) . PPaagggg
Taxing District (�� �_ 10a ODD. a oa-oaf r f r 36�
Assessed value of real property as of /r/J1Y"�=C"image!Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,amend year assessment date,parent year date eFfppliication legal or equi alle owner?
r� ❑ 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
❑ RealProperty ❑ Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller l r V
Address of mortgagee or contract seller(number and street afy,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? Has this deduction been requested If yes,state amount of deduction
other county on❑Yes El NO current ❑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(including 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 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 1 contract buyer of the dui ementioned property on date application is filed.
Signature(owner's tint name) Date(m ear)
rybessqf app(ncarnt(rprrpber and n\�y-v� q 26 70
thoorized by duly executed Power of Attorney or I 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 perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.