HomeMy WebLinkAboutMortgage_Hertel a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
L't& `'' FOR DEDUCTION FROM ASSESSED VALUATION 'g-�
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State Fonn 43709 0-15) J.�t
Presorted by Department of Local Government Finance F I , r�1'
INSTRUCTIONS: File Mark
Tb be filed in person or by mail. DEC 1 0 2018 Form filed with:
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 petty is 0 County Auditor
boated on or before January 5 of the immediately succeeding calendar year. „� County Recorder
2) Mobde/Manufactured Homes not assessed as Real Property:Must file with the Courrruggx���}}yy d
where the prrrpertyis located during the twelve(12)months before March 31 of each yet' a rssorkiht U !TOR
See reverse side for additional instructions and qualifications.
Appti(ra�fii((oowner contact buyer-see s on reverse side)
rU�/ )1 ( J en-2-Q,
Tax] jDistrict Key number I legal description Record number Page number
l zer-N-id-ic) Bo/ (R53 662 7 doi 8 '51k90
Assessed value of real property as of Mortgage I CoiraaA 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?
99(-c)d ❑ Yes 0 No
If no,what is his I her exact sham of interest? If owned with someone other than spouse,indicate with whom
if name on record is(Efferent than that of applicant,indicate below. Is the property in question:Annually Assessed
0 Real Property ❑ AnnuallyAssessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contact seller
Address of mortgagee or contract seller(number and sliest city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and„r/f:et,city,store,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
other county
pyn ❑iIndi ❑Yes El No on Yes 0 No
A person 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.
ill re er full name) r / Date(month,day,year)
Full r ' I address of applicant(number and sheet,city,state,and ZIP code)
V 3087 kit) So S Pc- v\cz-E-o\ L-N 'f 7(970
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 ' Date(month,day,year)
Address of authorized person (number and sheet 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.