HomeMy WebLinkAboutMortgage_Breeden C' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
f�< FOR DEDUCTION FROM ASSESSED VALUATION
eState Form 437O9(R13/10-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: 1g,
be filed in person or by mail. gpn .�- with:Tb 'ed :
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the deduction is sou ht Y�
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is A County Auditor
located on or before January 5 of the immediately succeeding calendar year. ���pp�
2) MobdeI Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the BOWmyO 4 County Recorder
where the property is located during the twelve(12)months before March 31 of eao5 year the deduction is sought
See reverse side for additional instructions and qualifications.
Applicant(owner or conmad buyer-see restrictions on reverse side) R
Don nle E &eecfem Cla, ON COUNTY AUDITO
T5liaA
,nrth , 2 mber 0 IZ 67�-302 -0_01 47 9.- Ole 20lier egtt ,
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the ap the sole
assessment date,current year assessment date,current year date of application ^9t 9� legal or eq,Yes ❑ r?
No
If no,what is his I her exact sham 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 di property in question:Annually Assessed
Cal Real Property 0 AnnuaffyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract se
bank � rrl rind
Address of mortgagee or coi seder(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 deduction been requested If yes,state amount of deduction
hiaa? ❑Yes 0 No ccun rrrent year?o r ❑Yes ElNo
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:
•
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.
X i,;(owner's full name).--Th. Date(month,day,year)
A �i1v2 9�(.P� bt / ll(��'{��MI
Fu1 te3Went a ot7pplican-f(numberand street city,stale,and ZIP code)
(3/0 6 4akt-
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of suborized 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.