HomeMy WebLinkAboutMortgage_Gill .•ra STATEMENT OF MORTGAGE O N CT DEBTEDNESS County Township Year
."r* • - FOR DEDUCTION FROM ASSESSED VALUATION
` : :" State Form 43709(R13/10-15)
S "i Presrnbed by Department of Local Government Finance
File Mark
INSTRUCTIONS: r ;r_-
b be filed in person or by mail
Filing Dates: 1) Real Property.Must be Completed and dated in the calendar year for which the deduction is sought I Fo j i 1
Must be filed or postmarked with the County Auditor or County Reconier of the county where the property is ` •unty Auditor
located on or before January 5 of the immediately succeeding calendar year Elty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the count)FEB .:
when;the property 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.
Appllcaan con
ntt(owner or bad buyer-see restrictions on reverse side)
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f lLcitp o . 13 Gr " n ssoNnnIINTY AIIf]ITOR
Tam District Key number/legal description Record n Page robe
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract Indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date.current year date of application legal or equitable owner?
- . - - c395ot) .. 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&recent than that of appraant,indicate below. ye property in question:Annually Assessed
Real Property 0 AnnuallyAssessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller - _
ITirgTi2u
Address of mortgagee or contract seller(number and street city,state,and ZIP code) Drawer NO 0? 9
Name of assignee or otter owner or holder of mortgage t/ /n
Card NO. / VL .�J(
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 deduction been requested If yes,state amount of deduction
��? ❑Yes ❑No on year?1 ❑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 recorders office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 - 204 20
Signature of County Auditor County • - Date(month,day,year)
t.1thA Q 9)'H -4 ("fii.5un- 2 - 8- zo1 5'
I/We certify under the penalty of perjury th 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.
Signior (owne name Date(month,day,year)
X _,r �. 2 8 Zoi9
Full r addrrtss of app t(number and street pty,stale,and ZIP code)
Person authorized by duly executed Power o/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.