HomeMy WebLinkAboutMortgage_Kell (2) } STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS ship Year
a FOR DEDUCTION FROM ASSESSED VALUATION
a State Form 43709(R13 110-15)
-'-- r-• Prescribed by Department of Local Government Finance
INSTRUCTIONS: - . OCT 2 zeta
Mark
To be filed in person or by mail. Form filed with:
Fling 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 petty i County Auditor
located on or before January 5 of the immediately succeeding calendar year. E p unty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Qp Y All tJ"
where the property is located during the twelve(12)months before March 31 of each year'91 ' rs sought
See reverse side for additional instructions and quafifications.
App- t(arrerm contact buyer 0sl on reverse side) 1
T District Key number I legal description Record number Page number
<(9�,2 ) a (o - b }- - 5 9- 03d - 000- 0 5a -0/2 cpan .99,77
Assesx vlfue of real property as of Mortgage 1 Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment dale:current year assessment date,current year date of application legal or equitable owner?
(03 4 0 Cr ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse.indicate with whom
If name on record is different than that of applicant indicate belovr. Is the property in question:Annually Assessed
0 Real Property 0 Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller`1( X I
Address of mortgagee or contact seller(number and sheet,city,state,and ZIP code)
Name of assignee or other owner or holder of mortg
Address of assignee(number and street city,state D••a tl'er No.
oDoes ther applicant own property in any If yes,wha C'a I,CI' t\ ••••• en requested If yes,state amount of deduction
in Indiana? ❑Yes El No O• Yes ❑No
A person is not entitled to this deduction un ••• '• •...• rail indebtedness that is recorded in the county
recorder's office(including any home equity tine w...__ at is the basis for the deduction.
COUNT r ..__
Deduction approved in the amount at
20 20 20 20 20 20 20
Signature of County Auditor County • Date(moma 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/co ct b r of the aforementioned property on date application is bled.
'
I(Signature( Date(month,day,year)
10 MiZ✓,Y•
\I-Full ad of a�fnumber and sheet,city,state, nil Pcod
Person authorized by duly executed Power of Attorney or by IC 6-1.1-1 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 510,000.