HomeMy WebLinkAboutMortgage_Hall (3) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
raj; FOR DEDUCTION FROM ASSESSED VALUATION `Cl1ounty Township gYear(n'f
Pres ed by Department
5) (lr`V1 � �' - 01X
- Pr to Form by 9(R13/n 0-1 of Local Government Finance ``UU�t f�JJ v\ IO
INSTRUCTIONS: File Ma \..,
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 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 County Auditor
located 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 County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Appiiant(ownecpr wnbact buyer-see reticdon on reve ' )
T District`J\;�„a1My�rnyr� )l..
of real pro$ sas of Mortgage!Cetera-1 indebtedness unpaid as of Mortgage I Contract indebtedness uni as of Is the applicant the sole
assessment currant year assessment dad,current year date of a 5 O V QJ . legal or❑ Yese ❑er?
No
If no,what is his I her exact share of interest? If owned with son ne other spouse,indicate with whom
If name on record is du4erent than that of applicant,indicate below: property in question:Annually Assessed
Real Property 0 AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller (n y g{{'
•
Address of mortgagee or contact seller(number and street • te,and ZIP code) )( ��ED
Name of assignee or other owner or holder of mortgage g
--- nrr 9_7 .2a1R_ -
Address of assignee(number and street city,state,and ZIP code) at 0/ g - 4.9 to o
Does applicant own property in any If yes,what county? what Taxing District? t of deduction
other county Drawer NO OR
in Indiana? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the I din the county
recorder's office(rnduding any home equity fine of credit that is recorded in the a
COUNTYA Card NO.
Deducton approved in the amount ott
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/contra« .uyer of the aforementioned property on date application is filed.
Sig ii r.d. ' e) Date(month,day year)
.R =Na- .address of a t city, and ZIP code)
: Lail
MOS
Person authorized by duly executed Power of Asoey or I 6-1.1-12-0.7 1 m Date(month,day.year)
Address of authorized person (number and street city,state,and ZIP code)
The penalties for penury can include imprisonment up to two and a half years and a fine not to exceed$10,000.