HomeMy WebLinkAboutMortgage_Hale (2) 4-s: STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
51- State Fonn 43709(R13/10-15)
Presorted by Department of Local Government Finance
INSTRUCTIONS: -r Ile Mark
To be filed in person or by mail. Farm filed with:
Filing Dates 1) Real Property.Must be completed and dated in the calendar year for which the ded L
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. t C �q ❑ County Recorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County A,$tb}oattib r k hry
where the properly 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.
Applicant(owner or con buyer-see resMot'onn rs re side U'!!
0 `Y r O �,IaS(1N COU� AUDITOR
Taxing District Key number/legal description Rxad number Page number
- -D1-too -f (' 9b1 -0a� 2201G C122C)
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment dale,current year assessment date,ahem year date of gpplicaWn legal or equitable owner?
330kDO, o(� ❑ yes ❑ No
If no,what is his I her exact share of interest? If owned with someone er than spouse,indicate with whom
If name on record is different than that of applicant,indicate belay. Is the property in question:Annually Assessed
0 Rea/Property ❑ Annual yAssessed
• Mobile Horne(IC 6-1.1-7)
Name of mortgagee or contract seller n
Address of mortgagee or contract seer(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 ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deducton been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes ❑No ,current year? ❑Yes ❑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 I contract buyer of the aforementioned property on date application is filed.
Ig owners il na;tie/ Date(month,day,year)
dreessofanuhber and city, ,and ZIP code) I — _I
ooto ssRtoL ttMA 4)67v
Person authorized by duly executed Power of Atbmey or by IC 61.1-12-0.7 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 510,000.