HomeMy WebLinkAboutMortgage_English STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
S
Slate Form 43709(R13/10-15)
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: •
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year e ed i
Must be filed or postmarked with the County Auditor or County R.
of properly property is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property sate:Must file y(�fM Qpu y� of the county ❑ County Recorder
when:the property is located during the twelve(12)months before Manic 3)sate
deduction is sought
See reverse side for additional instructions and qualifications.
Apr/ownero con'taJJGbuyer-were onrevesesde)—/
end ,tflQ /5h thin? A- •
TY AUDITO
Taxing District number I legal description �' Record number Page number
?-1.p'O1" 58-6/7 coo. 53o- O/8 120 t % kthi.E10
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage 1 Contract indebtedness unpaid as of Is the applicant the sole
assessment dam,current year assessment_u- dale,current year/�_ /, .date of application legal or equitatie owner?
F6ry phi got r✓�S/C �0i 000 0 Yes 0 No
If ro,what is his 1 her exact share of interest? f7 If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant indicate below. Is the property in question:Annually Assessed
❑ Real Property 0 AnnuallyAssessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 5i
Address of mortgagee or contract seller(number and street dry,sNte,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street dry,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
in Indiana? ❑Yes ❑No acomeennt fir??for ❑Yes El No
A person is not whiled 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(in lulling any home equity line of aedit 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 coned and that the applicant is a resident of Indiana and
owner I ct buyer of the re ned property on date application is tiled.
Signam s Date(month,day,year)
/A/3/totd�
Fug • address of app ( and dry,state,and ZIP code)
erson authorized by duty executed Power of Atmmey or by IC 6-1.1-12-0.7 Date(month,day.year)
Address of authorized person (number and street dry,state,and ZIP code)
The penalties for perjury can include imprisonment up to twv and a haff years and a fine not to exceed S10,000.