HomeMy WebLinkAboutMortgage_Null STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
itt-a FOR DEDUCTION FROM ASSESSED VALUATION It7! /CoNgu Township Year
�'� State Form 43709(R13/10.15) Y ', 9 '
Presamed by Department of Local Government Finance !!LL gg :ED
INSTRUCTIONS: APR 2 7 sfir Marx
To be filed in person or by mall. 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 orposlmariced with the County Auditor or County Recorder of the county where the/ perry I County Auditor
located on or before January 5 of the immediately succeeding calendar year. 1( .jarn111i
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the Counter Fir it s• h AU)IT❑OR unty Recorder
when the properly is located during the twehe(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant or c seeresb�ctiannss�onn rreevveersseeesside)
T - g District Key umber/legal description Record number Page number
el/ - 02a -/D - boo — ooq. el9G - qay ,Zit ) /83 (0
ecoccon value of real property as of ��11II Mortgage/Contact indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
assessment data current year 1 assessment date,current year date of application legal or equitable owner?
&O 00 p El Yes 0 N
If no,what is Iris/her exact sham of interest? If awned with someone other than kin,res.,indicate with whom .
If name on record is different than that of applicant,indicate below. Is the property in question:Annually Assessed
I1.osy Pmraty. fl Annually Assessed
Name of mortgagee or contact seller Q\,-1G7 70` �'C O
Address of mortgagee or contract seller(number and sheet city staatte,and ZIP coddee.)�� p`J Q x (.n 0 U o O —
1
—
Name of assignee or other owner or holder of mortgage .- ()I L—A C /
Ad of assignee(number and city,state,and ZIP code) `__ le \`o I ` `e
P'? NW ¢ T PE it — q - ti . 97A— C J
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested It yes,state amount of deduction
n Indiauna7 ❑Yes ❑No currrenmttyean` ❑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(inducing any home equity line of aedit 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.
satyr@( f jtua name) Z5- - — Date(month,day,year)
Fug resident ad c t(number and,p cry. .and LP e)
JJy3s S - owc,usu;lleR bsf-ce)l/ tti t£ 76 -s ?
Person authorized by duly executed Power of Attorney or by IC 8-1.1-12-0.7 / Date(month,day.year)
Address of authorized person (number and sheet city,state,and LP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 310,000.