HomeMy WebLinkAboutMortgage_Rohrscheib STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS —r. �
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FOR DEDUCTION FROM ASSESSED VALUATION A ��
�'- State Form 43709(R13/10-15)
�- Presorbed by Department of Local Government Finance SFr D Lu',3
INSTRUCTIONS: •
- _ File Mark
To be filed in person or by mail. n led with:
Filing Dates' 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought I I� nr r,
Must be filed orposfmarked with the County Auditor or County Recorder of the county where the property r� .-rY a( I fo}mty Auditor
boated on or before January 5 of the immediately succeeding calendar year. CilBSON COON
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county LI
County Recorder
where the properly 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.
Applicant or contract buyer fsee restrkeo on reverse side)
Tans stb t Key number/legal description Record number Page number
� � a6 -/a - /6 -io/ - coo, rAI -o,17 20i 36611
• Assessed value of real property of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
. assessment date,current year assessment date,current year date of application legal or equitable owner?
i 3 $, 41 ti /o ❑ Yes ❑ No
If no,what is his/her exact share of hderest? If owned with someone other than spouse,indicate with whom
1f name on record is different than that of applicant,indicate below. Is the property in question:Annually Assessed
❑Real Property 0 Annually
Home
Assessed
• Mobile�(IC
6-1.1-7)
Name of mortgagee or contract seller 71 /1
Address of mortgagee or contact seller(number and street ary,state,and ZIP code) //1/�
Name of assignee or other owner or tinter of mortgage / t tl g
Drawer NO !—"' f
Address of assignee(number and street city:stare,and ZIP code) ' /1/1,
•
Cd
Does applicant awn property in any If yes,what county? Mat Taxing District? Has this dedi `�T• NO. 'l•�pl•�l U1
other county on property 6
in Indiana? ❑Yes ❑No anent year,
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract rnaeoteaness that is recorded in the county
recorder's office(including any home equity fine 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.
XSignature(• ham Date(month,day,year)
UUUeee111 V/e/zor�-
Full -• ads F 1(_, u SBeet�ystare,and ,r,, de)� /�, t,r /
• 111777CCCLrr___... 4 /r—t�^-ez 1-- 'Ms— !7 c0 70
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 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.