HomeMy WebLinkAboutMortgage_Lundberg em�s,_� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
Ems;' FOR DEDUCTION FROM ASSESSED VALUATIONA 1 G� !-
.."" '' State Form 43709(R13/10-15) 5-N- O� 1 1akl nil J Q1yPrescribed by Department of Loral Government FinancefJ ��RJ�`U�ill::-- r1 O
INSTRUCTIONS: File Mark
To be filed in person or by maiL Form 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 poshnarked with the County Auditor or County Recorder of the county where the property is County Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ unty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
whem the property is located during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
• nt -or contract -see resaicbons on reverse . ' - 1
,ne u.� c Ihts 1 u Y,a
T D number/leg d number Page number
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Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortg /Contract indebtedness npaid as of Is the plirant the sole
assessment date,=rent year assessrtent date,current year date I^ rr++ legal ;table owner?
-7 ILk0o • Yes 0 No
If no,what is his/her exact share of interest? If owned with ne other than ypo,5e,indicate with whom
If name on rend i5 different than that of applicant,indicate below: s property in question:Annually Assessed
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller .
^ , � �,,
il seller(num an street,
F LED
Address of mortgagee or contract city,state,and ZIPcode)
ile) y ;1
Name of assignee or other canter or holder ofmo— 1 DEC 7 2018
Address of assignee(number and street dry,star /r /, /
Drawer 1
Does applicant own properly in any If yes,wha kakWiiioaaidN 111)yelt tspP nt of deduction
other county .
in Indiana? ❑Yes ❑No S U ❑Yes ❑No
A person is not entitled to this deduction unk Card NO. d5' o)'� contract indebtedness that is recorded in the county
recorder's office(including any home equity, )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 contract buyer of the aforem ntioned property on date application is filed.
Sig ( namey� ,JI`�� ,/ Dale(month,day,;reap."
tldA�r��I ssss'9/(v/�Lj„�`['y���u�+.`�.��G('d+^>u�� ctly,state,and (hod('`'1� �n 12 -1"l-1 .
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ad J t/` C start,
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Person authorized by duty executed Powelof Attorney or by IC 6-1.1-12-0.7 V Z 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.