HomeMy WebLinkAboutMortgage_Childress STATEMENT OF MORTGAGE OR CONTRACT INDEBTE 5 ) � Township Year
.f FOR DEDUCTION FROM ASSESSED VALUATION
<^ State Form 43709(R13/10-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: JAN 18 2019 File 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 ded s scull
Must be filed or postmarked with the County Auditor or County Recorder of the coin is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. (,LERRp�N C UNITY AUDITOR ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the co my Au o the county
where the propedy 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 contract buyer-see res p ns on reverse side)
T_79 District Key number I legal description Record number Page number
e - — /a -3i ... too -ooy.(si-oa7 plc / 9 a
Assessed value of real puuperty 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 dare,current year date of application legal or equitable owner?
❑ Yes ❑ No
If rio,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,imitate below: Is the property in question:Annually Assessed
❑ Real Property 0 Annually Assessed
- Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 5-/3
Address of mortgagee or contract seller(number and abeet city,state,and ZIP code) DI'a"ter No _
Name of assignee or other owner or holder of mortgage .'''•••.
Card 1\`O. .... I
Address of assignee(number and alit-et,city,state,and ZIP code)
•
Does applicant own property in any If yes,what county? What Taxing District? Has this deduces..--
in�Indiaia?nty ❑Yes ❑No aaiirenp nt ear? ❑Yes ❑No J
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 recorders 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.
re( full pa�e) >'L� Date(month,day year)
n I` a et .
1 , F e of applicant umberar/ street dty,state,and ZIP code)
Person authorized by duly executed Power of Artomey or by IC 1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet 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. •