HomeMy WebLinkAboutMortgage_Hicks (2) a �
STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS , ship Year
e� ' FOR DEDUCTION FROM ASSESSED VALUATION
�:' State Form 43709(R13110-15) 1_z:
Prescribed by Department of Local Government Finance
INSTRUCTIONS: 'JUL Iti 3 2ffq Mark
lb be filed in person or by mail. Form filed with:
Filing Dates: 1) Rea/Property.Must be completed and dated in the calendar year for which the deduction is sought
Must be filed or posbnadced with the County Auditor or County Recorder of the county where the;floe County Auditor
located on or before January 5 of the immediately succeeding calendar year. Nat I�I bounty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the CountyAWfcOii tfie IUMI*Y A1D4)
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((ow ct toyer-see ms on rrvgse side) , _
Tarim' g Key number 1 7��/'desai�v^�ppon./U--a�./1+9-Ycxi-aac�.& as -o a7 Record number
� "�
`AssessedJ14d value of real property as Mortgage/Contact indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
ase c nent date,current year assessment date current year date of application legal or equitable owner?
q/o 3 000 ❑ Yes ❑ No
If no.what is his I her exact share of interest? / If owned with someone other than spouse,indicate with whom
If name on record is different than that of appll ant,indicate below. Is the property in question:Annually Assessed
❑ Real Property 0 AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgageetg/ or contract seller
AddresS,Efrttgagee or�Mact seller(number and tit.ray,SsfM,aad71P code) .
Name of assignee or other owner or holder of mortgage •`/1`///V r�
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 ❑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 aedit 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 my Poi County • - --- Date(month,day,year)
I ,
I/ e certify under the penalty of perjury that the a oing information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned prop plication is filed.
S' -e(owner's fug name) \ ,'�'���,]'/``\^'',•*Lid'` �/f/�� //J� Dale Sa,yea/FtA 3 l E t ad t 3S0�' '� /Lf ! ewtk P�
Person 2uthorized by duly executed Power of Attomty or by IC 6-1.1-12-0.7 Date(month,day,)ear)
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.