HomeMy WebLinkAboutMortgage_Roe STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
el:+.;:_- FOR DEDUCTION FROM ASSESSED VALUATION
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�If State Form 43709(R13/10-15) �(01
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scribed by Department of Local Government Finance (/�
INSTRUCTIONS: Pit File Mark
b 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 deduction is sough
Must be filed or posbnarked with the County Auditor or County Recorder of the county whe pe - 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 ofmrye
where the property is located during the twelve(12)months before March 31 ofi�rh°. ii-deduction ht
See reverse ..0: for additional instructions and qualifications. S
Appu.c t(�• • contract restrictions on reverse side) C 'i
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T•/ - Key number I legal description cy¢riord number Page number
A i� 07 - / 7-07 /os- OW. ,% 3- Oa2 °R2 \9 1469
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant thesole
assessment date,current year assessment date,current year date of appl I legal or equitable owner?
/��1030 0 Yes 0 No
0 no,what is his/her exact share of interest? If owned with someone bluer than spouse,indicate with whom
If name on record is different than that of applicant indicate below: Is property in question:Annually Assessed
Real Property 0 Annually Assessed
Mobile Horne(IC 6-1.1-7)
Name of mortgagee camtract seller /�
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Address of mortgagee or contract seller(numa-Jan/street
rpE,bnd 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
other county on property for
in Indiana? ❑Yes El No current year? ❑Yes 0 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 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 Auditpr Civility • Date(month,day,year)
—
2...44s .41J/�4 ) 7A
I/We certify under the - natty 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 aforement' ned property on date application is filed.
Signature( tuff nam:c / _ Date(month,day,year)
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Person authorized by duly executed Power of 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 s10,0D0.