HomeMy WebLinkAboutMortgage_Michel (14) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15 I I . �l9
Presatbed by Depa r r•_nt of Local Government Finance �)�,SQ� 1 Nh�n�
INSTRUCTIONS: Y�[� ,(� File Mark
person or by mail.b be filed in , '-""l
Fo with:
Filing Oates 1) Real Property. . . .-. -•... - -. ..•-- .. r e calendar year for which the deduction is so
Must be filed or posbnarked with the County Auditor or County Recorder of the county where f 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 or
whem the property is located during the twelve(12)months before March 31 of each year the deduction t3
See reverse side for additional instructions and qualifications.i�
ner
conuatyer-lee Tans
nrQDIocI;fy on 1,8 I l �7 ^1 �fl OR
Taxing District v i(ey lJegal tlgsrrpf �(� .0 �l.- � ' '' (iItl SC O AU1 „ number
I`GI L3 I I%4��Z
Assxvrf value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage Contract indebtedness id as of Is the applicant the miler?
assessment date,current year assessment date,current year date legal or eq ble owneR
OPE IYes ❑ No
If no.what is his/her exact share of interest? If owned with ne other elan cp n lost indicate with whom
If name on record is different than that of applicant,indicate below: lye property in question:Annually Assessed
Real Property 0 Mobile y Assessed
• Mobde Home(IC 6-1.1-7)
Name of mortgagr len or(�ntract seller 1 PreicAcck ELL .
ress of mortgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of 'Kw Wage
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 CI No current year? ❑Yes ❑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 0 20 20• 20
Signature of County Au e Tg
VI ` rtCountyDate ,h,pay�-�yS � I .JII/We certify under the penalty of pthat above an mg information is t nd correct and that the applicant is a resid t of Indiana and
owner/contract buyer of the aforementioned property on date application is filed. �"
\/ Signaure( name) Date'(netri r,'ya ll�a/1�
rJt\Full resident address of applicant(number and street,city,state,and ZIP code) 1/VJ" I,-J\ I ul1
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$10,000.