HomeMy WebLinkAboutMortgage_Livermore (4) s, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS n ET hip Year
'or- FOR DEDUCTION FROM ASSESSED VALUATION
AI_ _1 State Foam 43709(R13/1615)
"�•-- Prescribed by Department of Local Government Finance
INSTRUCTIONS: . APR 2 5 2ff1*Marts
lb be filed in person or by mail. Form filed with:
Filing Dates 1) Real Properly:Must be completed and dated in the calendar year for which the deduction is sough. j��,�
Must be filed or postmarked with the County Auditor or County Recorder of the county where the County Auditor
boated on or before January 5 of the immediately succeeding calendar year. 777���''��` 77
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the countyyA ?&t�r2 ryY A(),p��ounty 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 additional instructions and qualifications. •
t(owner or contrary buyer-see restdc5ons on rte side
an1.1 key number I legal description Record number Page number
a — /i -i.x --,3o1 -. 0 ,007,. 71/ 9- o - 8> act ) S .13.s7
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,tuner*year assessment date,anent year date of application legal or equitable owner?
6o ooa ❑ Yes 0 No
If no,what is his/her exact share of interest? If owned with someode other than spouse,indicate with whom
if name on record is different than that of applicant indicate below: Is the in question:Annually Assessed
o Property ❑ Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract h / _
Address of mortgagee or contract seller(number and street,city,stale,and ZIP code) (�
Name of assignee or other owner or holder of uuitvage \ _ O O_ ,
Address of assignee(number and sheet city,state,and ZIP code) iJ ��j--'�'\f�
Does applicant own property in any If yes,what county? What Taxing District? 1
other in Indiana? ❑Yes ❑No C) \4
A person is not entitled to this deduction unless the person has a balance on the person': , wily
recorder's office(including any home equity line of credit that is recorded in the county re S O, O O T v
COUNTY AUDITO
Deduction approved in the amount ot.
ao (8 - la15 1
20 20 20 20 _
Signature of County Auditor County 3 — a D N
I/We certify under the penalty of perjury that the above and foregoing information S true and correct arm mar um..m....—......_.. 1 and
owner!contract buyer of the aforementioned property on date application is filed.
Signature(owner's lull name) Data(month,day,year)
/`p
v F of app number and sheet city.state,and ZIP code)
lh I/S S Rta fib vrety (restf Derr PRt, eCTo,- 10-- 47 61 6
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 sheet 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 510,000.