HomeMy WebLinkAboutMortgage_Dersch sa STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
't=ci` FOR DEDUCTION FROM ASSESSED VALUATION �1
'- State form 43709(R13I 10-15) p ,
<-22-:- Prescribed by Department of Local Government Futance ��L9
fir. 1
INSTRUCTIONS: . File Mark
To be filed in person or by mail. A U Gfd2rrTep "
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year -❑J rder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the coun Icy
where the property is located during the twelve(12)months before March 31 of each year the deduct-iced ` COUNTY AUDITOR
See reverse side for additional instructions and qualifications. number
App6p t(owrreror contract buyer-sGe side)
� r� Off+ .yt �.( l C._
.
TaringDis Key number 13- c -
o - en - 00 to 2-0 ` 1
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,=rent year assessment date,anent year date of application tffiC) legal or equitable owner?
14 —I ' > ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other spouse,indicate with whom
ff name on record is different than that of appfi ant,indicate below is theme in question:Annually Assessed
8'Reaml yPmperty ❑ Annually Assessed
Mantle Mn(IC 6-1.1-7)
Name of mortgagee octract seller ScLn a (tom' \ w,
Address of mortgagee or contract seller(number and street city,state,and VI'code)
`L^�.1J1/,1
Name of assignee or other owner or holder of mortgage _
Address of assignee(number and street city,state,and ZIP code) !-1 Q 1 �/'
Does applicant own property in any If yes,what county? Mat Taxing District? He D C a�� C I NO CJS t o n
other on
in Indiana? Yes El No as
A person is not entitled to this deduction unless the person has a balance on the person's m Card NO. 5 :My
recorder's office(including any home equity line of credit that is recorded in the county moor
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. (�� (�
ig re( sfug name i� fate j' - ()- Ice
resident ad /'�of ftt(number and scree and ZIP code) f\ /� lO� r
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Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 I Date(month, ytta0
Address of authorized person (number and street 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.