HomeMy WebLinkAboutMortgage_Ravellette (4) ,< STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
` ''' FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
�- Presatbed by Department of Local Government Finance
INSTRUCTIONS:
file Mont- # lao/ed
To be filed in person or by mail. S uno osglr� F rmF nm fi •
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction rs)so h�
Must be filed or postmarked with the County Auditor or County Recorder of the county where rfy is curt ttor
located on or before January 5 of the immediately succeeding calendar year. 1
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the County A•Wf r r of •- ' •• �.�L . it rUer
where the property is located during the twelve(12)months before Mardi 31 of each year the deduction';�
See reverse side for additional instructions and qualifications. lajSUea)JO '•3uej r aipe lewj 01 pelgns
Appliant(center o contract biro(-seerestrictonsonreverseside) NOIJYXVI HINga1i3til11fQ, %
d 4�r e ^�-�4c ,
Ta m District Key number/l gal description Record n rO r
• �i6-`,a - On - 4Ok CO\. giL- Og. 1. 009
Assessed value of real property as of Mortgage/Contract indebtedness paid as of Mortgage I Contract he-"--_-cc u•4 urx n[A9 itidaNSihtl 'stile
aPsessmentt date,ccurrrent^year acre Year date of c'�1'�f{, o�(�� (�'�((' L+s�iegai or equitable owner?
If m,what is his)Tier share of interest? � 1� If owned with someone other attar{a,Indicate with whom Yes ❑ No
If name on record is different than that of applicant,indicate below. Is the in question:Annually Assessed
• y ❑ �MObt� 1.1-7)
Name of mo .-..ee or contract seller
It ! fit_ 1 • 1 • • ' to,a_ Ds . 1
Address of • •-gee or conbact seller(number and street city,state,and ZIP code) - 1 O v c �yJ C (l Q- \1
e
Name of assignee or other owner or holder of mortgage "k-t3 014 B o\?- a 009
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Address of assignee(number and street city,state,and ZIP code) �- k --1 G 0 (0( a I , lid
o�applicant own property in any If yes,what county? What Taxing District? Has this ..__.. ,.
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 ot.
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 mentioned property on date application is filed.
Signature(owners hub name) �/�/ Date(month,da[y,_year) Q�
Full nt address of applicant(number and state,and ZIP code)
x o 3 P_la r V i ncv-}(m . h) 4-) 1.0-7 c�7 .
Person authonzed 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'beet,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.