HomeMy WebLinkAboutMortgage_Simpson STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
; 1 s FOR DEDUCTION FROM ASSESSED VALUATION
.-y" -Y State Fond 43709(R13/10-15)
S‘F-ii:I Presa3ed by Department of Loral Government Finance
INSTRUCTIONS:
File Mark
To be filed in person or by mail.
t.o1a Fonn flied with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the is so g/4
Must be filed or postmarked with the County Auditor or County Recorder of the county cot 'th 'property i ❑ County Auditor
boated on or before January 5 of the immediately succeeding calendar year. UC-" C County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of th \-(O
where the property is located during the twelve(12)months before March 31 of each year the clad :
See reverse side for additional instructions and qualifications. I RS`14l
nt(owner or contract buyer-see on reverse sale ON�+
�h, e a K e--,\\ (Y�l��M 1�Q. 1 r G�05n numbere
L �Taxm9 D"aact t't�� � . 1 0 a -C/ I . 1 I `O- 0. -d C/1d6 �J V L l
An p( l P
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of I is the applicent the sole
assessment date,current year assessment date,rent year date of apple p'y-�,c-�PGl '__-r mrelqu�itable owner?
S kiaO/LMJ`,-S� 1 W yes ❑ No
If n o,what is his I her exact share of interest? If owned with someone other Ryan spouse,indicate with whom
If name on record is different than that of appri ant,indite below: Is the rat welly in question:Annually Assessed
0 Real Property 0 AnntwgyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or con cr seller
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Address of mortgagee or contact seller(number and street,city,state and ZIP code)
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Name of assignee or other owner or holder of mortgage
Address of assignee(number and sheet,city,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
other in Indiana? ❑Yes ❑No current year?on property for ❑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 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)
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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 I contract buyer of the aforementioned property on date application is filed.
Signature(owners full e) Date(month,day,year)
X/ 14(/' I � a- 7�-gig .
Full residBTT t( umber and street city,state,and ZIP cod
X -13� .� St�r�lr.t�P_ T-i 0�— 25\---) .
Person uuuxxtze u.y duly executed Power ofAbomey or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street iffy,state,and ZIP cede)
The penalties for perjury can include imprisonment up to Iwo and a half years and a fine not to exceed S 10,000.