HomeMy WebLinkAboutMortgage_Cobb STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
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FOR DEDUCTION FROM ASSESSED VALUATION g g
State Form 43709(R73/10.15) FD
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Presrnbed by Department of Local Government finance . J
File Mark
INSTRUCTIONS:
To be filed in person or by mail. JAN 2 8 2019 Forth filed wi h:
Filing Dater 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 perry is 0 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 Auditor
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where the property is located during the twelve(12)months before Mardi 31 of each yeaa3Rllifabit@4QJtf IRlititAUJITOR
See reverse side for additional instructions and qualifications.
Applicant(Tyner or tartar-see ✓ on reverse side)
T g Disbi Key number/legal description Record number Page number
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Assessed value of real property as of I Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
,emcvnent date,aurent year assessment date,current year date of application 71 legal or equitable owner?
ai oo 0 ❑ Yes 0 No
II no,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 indicate below. Is the property in question:Annually Assessed
❑ Real Property 0 AnnuallyAssessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 5 - -
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Address of mortgagee or contract seller(number and street,city,sbte,and ZIP code) Drawer NO .
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Name of assignee or other ovmer or holder of mortgage
Card NO. .....
................
Address of assignee(number and street city,state,and ZIP code)
D Does
applicant own property in any If yes,what county? what Taxing District? Has on thisucs„..,.�___._
in Indiana? ❑Yes ❑No current year?for ❑Yes ❑No I I
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recopied in the county
recorders 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: -
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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!contract buyer of the aforementioned property on date application is filed.
Signature(owner's full name) Date(month,day,year)
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/FW ddre lass of awfavnt(number and street,city state,and ZIP code)
Person authorized by duly ` r'executed Poweerof 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.