HomeMy WebLinkAboutMortgage_Wilcox STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
t>? t'; State Form 43709(R13/10-75)
Prescribed by Department of Local Government Finance
INSTRUCTIONS:
File Mark
To be filed in person or by mall. rm filed with:
Filing Data 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 Cgy.Qty Auditor
located on or before January 5 of the immediately succeeding calendar year. corder
2) Mobde/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the countyhn
where the properly is located during the tweve(12)months before March 31 of each year the deduction is sou* r
See reverse side for additional instructions and qualifications.
Applicant(owner or contrail buyer-see restrictions on reverse side) G/e 20/8
C,\Qr\4 LD1 1 C-0 K soH
y Taxing District Key number/legal um
Aecrceal value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is Men nt the sole
a<r ement date,oareM year assessment date,anent year date of application legal or�e able owner?
0-70, coogm< ❑ No
If no,what is his/her exact sham of interest? If owned with someone other than sr,inQIcate with whom
If name on record is different than that of applicant,ldirate below. Is the property in question:Annually Assessed
❑Real Property ❑ Annually Assessed
Mobile Home(1C 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract serer(number and sire dry,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,slate,and ZIP code)
Does applicant am property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes ❑No anent year? ❑Yes ❑No
A perm 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(owners fun name) Date(month,day,year)
�[ ,o � •�..1 n-a -is
Full resident address of applicant(number and ahu4 state,and ZIP code)
,)( `] to }'i �$. la U o W- c \A.Ae-4-1r5 t,: 11-1 .2, 't 7C.e.a—
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-01 — Date(month,day,year)
Address of authorized person (number and street ay,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a hat years and a fine not to exceed S10,000. --