HomeMy WebLinkAboutMortgage_Griesamer STATEMENT OF MORTGAGE OR CONTRACT INDEBTED „; Township Year
s-.=- FOR DEDUCTION FROM ASSESSED VALUATION gg
State Form dby (R13/10-15)
Prescribed by Department I,
of Local Government Finance
INSTRUCTIONS: MAY 1 0 2018 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 ded n is so ht
Must be filed orposbnarked with the County Auditor or County Recorder of the cour�ntT�ryrs County Auditor
located on or before January 5 of the immediately succeeding calendar year /0
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file withr9leeud` AIy(AQIdNIM At#DtPOOR County Recorder
where Nye nal instructions is located ddqua the qualifications.
(12)months before Mardi 31 of each year the deduction is sought L��
See reverse side for additional instnrctions and quafificatiorts.
Apprtant(owner or- j.. • . .,''' on reverse side) � -- � ,,,, ll
• /^/µ JZ�SL�OI��JV 4j/-7�1&
Taring District / i - /legal r7esa�4on Record number Page number
Assessed value of real property as d Mortgage ebfedness unpaid as of Mortgage!Contact indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment n year date of application legal or equitable owner?
(35600 ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than cy ,cp,indicate with whom
If name on record 5 different than that of applicant indicate belay. Is the property in question:Annually Assessed
[�IReal Property ❑ AnnuallyAssessed
• ICJ Nbbtle Home(IC 6-1.1-7)
Name of mortgagee or contract ts
Address of mortgagee or contract seller umVT ' r)
state,/(andnd/ZZIP cod
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street qty,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 P for
in Indiana? ❑Yes ❑No curter 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 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.
Signature(awl pre) Date(month,day year)
Fydlfesident address of applicant(number and street,qty,state,and ZIP code)
�`t o21Z— I/ Bra 4.14- 5 i,
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$10,000.