HomeMy WebLinkAboutMortgage_Hipp STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
is FOR DEDUCTION FROM ASSESSED VALUATION `1-\1T�-� ' . 21
1' Stale Form 43709(R13110.15) ,rl Zbi9
- Presu�lnd by Department of Local Government Finance �� 11��-��1//""��+��
INSTRUCTIONS: File Mark
To be filed in person or by mait filed with:
Filing Dates: 1) Real Property:Must 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 properly is County Auditor
located on or before January 5 of the immediately suxeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county 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 instnrctions and qualifications.
Applicant( or not buyer on revers�ror) ^ -
T • g CY Key number/legal }Ildescn i f�,n,r/1/— Q 'O �� Record `pe; Page number�—
° • fo�(�-k� ti n� . $qU j 6 1l{12�
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage Contract indebtedness ugqgQ�eid as of Is the q' nt the sole
assessment date,current year assessment date,current year date of pl vap on, legal or �tde owner?
UU on,_ es ❑ No
If no,what is his/her exact share of interest? If owned with oe kif 4n spouse,indicate with whom
if name on record is different than that of applicant indicate below: Is a property in question.Annually Assessed
eat Property 0 AnnuallyAssessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller /'� /- m '�
5:21
Address of mortgagee or contact seller(number city,state,and ZIP code) I( ,i
1®l"'1 Ill
Name of assignee or other owner or holder of mortgage (
Address of assignee(numberano a,,, O 18 - Sal 3 -5- �1AY "15 [U19
Does applicant own property in an Has this deduction been wgypsted y [ m of deduction
in��7 El Yes ❑NI Drawer NO on
R COMMON
h7Q1°f(If�'
A person is not entitled to this c on's mortgage or contract indebted Q s Atli l}egged in the county
recorder's office(including any y recorder's office)that is the basis for the deduction.
Card NO. TOR
Deduction at oved the amount of
20 20 ip 20 20 20 20' 20
Signature of ,. . County Date( 1th,dayarL
: -11\jak (g‘16••:
RIOS
I/We ce ' under the penalty of perjury that the above and foregoing information is and correct and that the applicant a restlent of Indiana and
owner I contract buyer of the aforementioned property on date application is filed.
X Signa`ttuur�r (owners full
(/name)
mDale( Kayla
Fug resident ad oIdppfiant(numb„field street " state, Pcode) —1 1
1\a S )ofw\o• t r ° t 3� k C39
•
Person authorized by uy executed Power of Attordey or by IC 6-1.1-12-0.y/ Date(month,day.year)
Address of authorized person (number and sheet city,state,and ZIP code)
The penalties for penury can include imprisonment up to two and a half years and a fine not to exceed S10,000. - - -- - -