HomeMy WebLinkAboutMortgage_Bates STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
= 1 FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15) -�Y LED
`— Prescribed by Department of Local Government Finance y ti
INSTRUCTIONS: a L Ile Mark
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 t pp
Must be filed or postmarked with the County Auditor or County Raw der of the county whl rt �k ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property Must file with the County v 'or of th co
th where e property is located during the Meese(12)months before March 31 of each year �rght
See reverse side for additional instructions and qualifications. (MASON CCM INTY A(JDITnp
Applicantonu//Zb&a buyer ra son reverse side) N /y-� ['2'/ �7 ('� j 1
T /r/�lnUrint� totLfJJ�n1-(„�„t number
/-1,J,descriptionx- 12-
n/ye - 20`T'WI- 534-02--a Record( r Page number
Assessed vale of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment(+ date, ,
current te, year date of application legal or eq a owner?
(U0ii091 i f 1 kb, oO 0 Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than comm.,indicate with whom
If name on record is different than that of applicant indicate below: , Is thegP�o'petty in question:Annually Assessed
I� ---Property 0 Annually Assessed•
Mobile Home(IC
Nacre of mortgagee or contract seller
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage-
Address of assignee(number and street,city state,and /3j�t'r65 I Iaom As C..Does a liant own in anyIf yes,what coun T' I -f 4 ).11 62494 y nested If
applicant
,{, lq yes,state amount of deduction
other c
in Indiana? Yes ❑No ❑No
A person is not entitled to this deduction unless tic , I q - k (p 5 .ldebtedness that is recorded in the county
recorder's office(including any home equity tine r le basis for the deduction.
Deduction approved in the amount of.
20 20 20 20 20 ' 20' 20
Sgnatua of ra•,.•. C.,.,...tI I r - !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 afo ntioned properyryn date application is filed.
Signature(owner's Mine J Date(month,day,year)
\Xer and q� � �C — I- 11- 19
I� Full
f Lot ( d , f tc� i2 �1 nn 1.760-70
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 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.