HomeMy WebLinkAboutMortgage_Collins s STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cour. tr Year
'r ' :,, FOR DEDUCTION FROM ASSESSED VALUATION
',`-,tf °:z State Form 43709(R13 1 10-15)
S r Prescribed by Department of Local Government Finance •
INSTRUCTIONS: • APff(16 Ma11818
lb 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 sought /!
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property i Auditor
located on or before January 5 of the immediately succeeding calendar year. 7�W un B
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor o�+6&QhlyC OU V . O1�1 U order
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
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Assessed value of real property as of I Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant sole
assessment data,run rd year assessment date,current year date of a legal or equitable owner?
6070 ❑ yes 0 N
r 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
• Property ❑ Annually
I Mobile Home pc&1.1-7)
Name of mortgagee el contract seller /s� ide�
mortgagee contract Address of rtgagee or contra seller(number and street city state,and ZIP code)
Name of assignee or other owner of
•C /$ 1..? ` Z a'cl -d-/o c7/
Address of assignee(number and 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 property for
in Indiana? ❑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
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 —�- —
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Signature of County Auction _ County C t 1�S 1G �, CU,_
I/We certify under the penalty of perjury that the above and foregoing information is h off.O l --no ana and
owner(contract buyer of the aforementioned property on date application is filed.
Si (owner's ha name) ` D:h 1 'Gr
Th ,v,1,P,1 J)fl14fM) • I s o y
Full resident address of (number and street city,state,and ZIP code)
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Person authorized by duly executed Powef of Attorney or by IC 6-1.4-12-0.7 Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
The penalties for penurycan include imprisonment up to two and a half years and a fine not to exceed$10,000.