HomeMy WebLinkAboutMortgage_Hall : STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
11- State Form 43709(R13110-15) 5-I 4"-� 4
Prescribed by Department of Local Govemment Finance mV P mt. I Ot ()coo
INSTRUCTIONS: • File Mark
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Properly.Must be completed and dated in the calendar year for which the deduction is sought
Must be filed orpncbnarked 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.
2) Mobile IManufactured Homes not assessed as Real Property:Must file with the County Auditor of the county 0 County Recorder
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(owner or contract dryer-see restrictions on reverse side)
V.in \ 11 Q inn c' ( (1C -c-0 •l . �0.k\
t Key numbe
R m �
" zle ElQ (+k - o\\ °OLs— 256g .
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,aimed year assessment date,anent year date of application legal or. �
equitable owner?
If no,what is his 1 her exact share of interest? If owned with someone ohei than spouse,indicate with whom
If name on record is ddferent than that of appricant,indicate below: Is the
cs . ..> ' , -Annually Assessed
Ilri : u7y—❑ AnnualtyAssessed
(� 1n1 2/� ,,1 1A/ �(p�( Mobile Home(C 6-1.1-7)
N cat rtgrtga9ee arconfra 1 1 C\ n X k JW�-_ �. y�
Address off\mortgaggeevor contract seller(number and brhrt city,slate,and ZIP code) 1.0(
M0 :Niac‘
Name of assignee or other owner or,t'nW nr.ry nrvtnane OR
Address of assignee(number and s �(/.,/11� n ON COVNt
Does applicant own property in any Drawer NO V ( U Has this deduction D2een requested If yes,state amount of deduction
other in Indiana?an ty ❑Yes ❑No ^/� on
ellYr? Dyes 0 No
A person is not entitled to this dr ?ail n's mortgage or contract indebtedness that is recorded in the county
recorder's office including any t C 1"O NO. ...... ... •recorder's office)that is the basis for the deduction.
. :OR
Deduction approved in the amount of
•
20 20 20 20 , 20 ' 20' 20
ST oturpaunty Auditor ...iatic k /. county _ Date(moothafirel
I/We certify under the penalty of perjury tt;the Shdve and foregoing information is true and coned and that the applicant is a resident of Indiana and
owner 1 contract buyer of the aforementioned property on date application is filed.
Signature(owner's full name) ( a
cr
Full resident address of applicant(number and street,city,slate,and ZIP code)
74 7 Xi/n dill'n //14ZLe7Ori(/f7-N 4/7o VC/
Person authorized by duty 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 S10,000. - -