HomeMy WebLinkAboutMortgage_Smith STATEMENT OF MORTGAGE OR CONTRACT INDE l si�, y1 Township Year
FOR DEDUCTION FROM ASSESSED VALUATION J 'I'
- State Fonn 43709(R13/10-15)
Presrnbed by Department of Local Government Finance
AUG 1 0 2 U i(S
INSTRUCTIONS: File Mark
To be filed in person or by mail Form filed with:
F i l i n g D a t e s 1) Real P r o p e r t y Must be c o m p l e t e d and dated i n the c a l e n d a r year f o r which the • u c t i o, . ••• t
Must be filed or postmarked with the County Auditor or County Recorder of the:i1• • : ' • - •roperryys ❑ County Auditor
located on or befom January 5 of the immediately succeeding celendapjgsON COUNTY A DITOK
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county ❑ County 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.
Apprxant(owner contract see restrictions on reverse side) Cril G--e— /' • a- c5o n C L7 ISY;1-t.
Taxing District Key number/legal description Record number Page number
0a� � z4 -0,5 -.2,3/nook 083 0/7
Assessed value of real p as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment dare, ear assessment anent year date of application legal or equitable owner?
C"C^C3 ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other than slxn•ea,indicate with whom
If name on record is different than that of applicant indicate below Is the property in question:Annually Assessed
Meal Property ❑ Annual .Assessed
Mobile Honhe.(IC.6-1.1-71_-
Name of mortgagee or contract seder
E 7`! Y1`�
Address of mortgagee or contract seller(number and street dry,state,and ZIP code) v t,� n (Ih ��
Name of assignee or other owner or holder of mortgage V-•""r' 7.\� _
Address of assignee(number and street dry,state,and ZIP code) 18-a ' I 1
Does applicant own property in any If yes,what county? What Taxing District? Has this dteyducuun peen requested l If yes,state amount of deduction
in Indiana? ❑Yes ❑No aoemeiWyeea r Ekes ❑No 1.
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(owner's fu Date(month,day,year)
Full resident address of applicant(number and street city,state,and ZIP e)
cod
3/O4/ 6. 4.1e0 A V14.5 •Paa/I a, c17666
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 street dry,slate,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.