HomeMy WebLinkAboutMortgage_Cook �e<: • STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
tit--.• FOR DEDUCTION FROM ASSESSED VALUATION r1
�'- State Form 43709(R13110-15) \�.1`' ��``�
. . Presoibed by Department of Local Government Finance G\ 1/J11 GV
INSTRUCTIONS: J File Mark
lb be filed in person or by mail. Fo led with:
Filing Dater 1) Real Property.Mull 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 property is 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 of the county
where 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.
Applicant ?w eror coma semis on reverse side)
\M Upp l,�
Taxis District Key legal Record number a nun r
�-r cad -d -L2-4 - 1 , SIC o � �/�'uY�J .
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contact indebtedne5synpaid•as of Is the applicant the sole
assessment date,amens year assessment date,current year date
gee
Wno,what is his I her exact share of interest? If owned with olheolthan spou indira om 1 1
If name on record is different than that of applicant,indicate below: 1: e. . o� 14`e' guest oi:AnnuAssessedsedy Assessed
_VA:-. property r �yr.- . d _ ,
((( r r� Mobile Hone(IC 6-1.1-7)
e"-- L.Name of mortgagee or contrail seller ` ' I '
Address of mortgagee or contract seller(number and streeett city,state,and ZIP code)I 7�
Name of assignee or other owner or holder of mortgage J ,Z
Address of assignee(number and street city,state,and ZIP code) g
APR 1 8 2019
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? ❑Y-E 0
O.A person is not entitled to this deduction unless the person has a balance on the person's mortgage or own r. ' - ',.--..'r •at is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's oifitleil KA%6€)Ut T95d%RMa lle bn.
' COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20_ 20 20' 20
Sig of County-Audi Iel l ^ n��\ County Date(month1 BK yetar�
I/We certify underJJthe penalty of perjury at nil 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.K‘Signat yeQ�
re(own /0 name) �(•nfirdr,day y l
Fug r ern ad of fxan number and sheet,city,stale,and e) 1 ,
Gde l Jsk P .- �L y�-6k9
Person authorized by duly executed Power of yetomey oI by IC 6-1.1-12-0,7 Date(month,dirt yealry. '
Address of authorized person (number and street city,state,and ZIP code) Lir(J� (Jl(
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.