HomeMy WebLinkAboutMortgage_Littlepage (2) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
. FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10.15)
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS:
To be filed in person or by mail. JAN • 0n,ncnwith:
Filing Oaten 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought
Must be filed orpostmarked 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. • 41 �Z:.- •-Recorder
2) Mobile I Manufactured Homes not assessed as Real Property Must file with the County Auditor o the co '^, r -g711j
where the property is located during the twelve(12)months before March 31 of each year the ded bUNTY
See reverse side for additional instructions and qualifications. AUDITOR
Appti (w or contract buyer-see )
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Taxing District Al mber oa 9 /O/ ooa e '/o- O19 acss
Assessed value of real property as of Mortgage I Contact indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole'
assessment date,current year assessment date,current year date of ap ex., or equitable owner?
y ❑ Yes ❑ No
If no,what is his I her exact share of interest?' If owned with someone other than spouse,indicate with whom
If name on record is different than that of applcant,indicate below: 575 pointy in question:Annually Assessed
Real Property ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Gi
(-Liel-6-.4‘. (7f22---,---°
Address of mortgagee or contract seller(number and street dry,state,and ZIP code)
Name of assignee or other owner or holder. 4 ge ��j�///J !f /J 9/5"
/I/ o /i.r/! ,-,7, e add
Address of assignee(number and sthct,dty, n6f nd 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 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 fine 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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1 20- 20 20 20 20 ' 20' 20
Signature of County Auditor County Date(month,day,year)
I 1 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 1 co ct buyer of e aforementioned property on date application is filed.
Signature( am Date(moudr,day,year)
1' Full of a t tuber and -dry,state,arid Le)
CAC-
Person authorized by duly executed Power of Attorney or by IC 6-1if-12-0.7 Date(month,day.year)
Address of authorized person (number and street city,state,and CLIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.