HomeMy WebLinkAboutMortgage_Fox (2) e!, STATEMENT
DEDUC IO OF MORTGASS S ED VALUAT INDEBTE E ourtty Tship Year
FOR DEDUCTION FROM ASSESSED VALUATIO I State Fonn 43709(R13/10-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: MAR 2 3.2°1?' 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 deduction is e^Must be filed orpost narked with the County Auditor or County Recorder of -oou f...,.f.`the property is County Auditor
located on or before January 5 of the immediately succeeding calendar ye.ft, , —111"7"r
2) Mobile/Manufactured Homes not assessed as Real Property:Must file "fr radii-6Y Xu county County Recorder
where the property is located during the twelve(12)months before Ma1$)S a ft e�drYh—y>arthe deduction is sought
See reverse side for additional instructions and qualifications.
Ap m�or contract Tom-r 7 • , i rode) om .
�isttrrvt. �J Keylnumbmberllegal Q,�/des description '4~"J- ( Record number Page number
v a6-19- z8 iv ooO 76 � S zai8' 953
Assessed value of real property as of Mortgage rLOrmacY indebtedness unpaid as of Mortgage 1 Contract indebtedness unpaid as of Is the applicant the sole
assessment date,arnerd year assessment date, t year date of application legal or equitable own
'7500 0 owner?
❑ Yes ❑ No
If o,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 appficent,indicate below: Is the property in question:Annually Assessed
(teal Property ❑ MnuallyAssessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee a mortgagee wntraer
Address of rtgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or otter owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code) .
Does
ots applicant t own property in any If yes,what county? What Taxing District? He 9 O• •..•••• m
in Indiana? ❑Yes ❑No air, v i 1v,•fry ��....L.�r
A person is not entitled to this deduction unless the person has a balance on the person's me 1 J- ••..••••• my
recorder's office(including any home equity!me of credit that is recorded in the county recoro •..••
COUNTY AUDITOR CCXVa ° .-,n �j
Deduction approved in the amount ot. .A ile f vV Y i
20 20 20_ 20 2t I --I 20 20
Signature of County Auditor County - Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing informations true and correct and that the applicant is a resident of Indiana and
�Oowner/contract buyer of the aforementioned property on date application is filed.
i ner's lug
Date(month,day,year)
'^�'p^^pr'r—���� 3-c2,3-/ F
Full resident addrea applicant(number and street of t state,and ZIP code)
>° 156gK Coo S F-i;3r/f/lc1,, 174 47648-
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet city state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a hall years and a fine not to exceed$10,000.