HomeMy WebLinkAboutMortgage_Madison (2) eSTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION ///1�� ZOSiate Form 43709(Rl3l10.15) C3 GI�C(,4 N o� ` .Prescnbed by Do.. ' of Local GovernmentCCCL111 Finance JJJ..JJJ'�"1
INSTRUCTIONS: 4 I p cl M W 4:1 C °� 9I . IC File Mark
To be filed in person or by mail. 1 =�Q �1 ' f l� Fbrm 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 property is ounty Auditor
located on or before January 5 of the immediately succeeding 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 instructions and qualifications.
Applicant owner or ntract buyer re s on reverse side)�y-y� ,, ,/
Taxis `YC( Q R A /- atria. / r! ad, 6 '
Key number/legal description Record number Page number
Z4-/2-es- t3oi- cny.39/-02S of 2954
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as bl Is the applicant the sole
assessment data,current year assessment dale,current year date of application legal or eq itable owner?
75, 7/0, ' Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than cprvi¢n,indicate with whom
If name on record is different than that of applicant,indicate below: Is property in question:Annually Assessed
Real Property 0 Ann - •
`Name of r(g seller r / r /� r� t
jy-I/ y/��7�� i JfJ/W/tact f` CliAltd.
Address of mortgagee or contr;n eller(number and street cry:sta and 6 code) 111111` 312p19
Name of assignee or other ovmer or holder of mortgage 3u
Ir n uGU NT dR
Address of assignee(number and street,city,state,and ZIPcode)
de) N"" llJ�
Does
�1Bs0
other tam property in arty IF yes,what county? What Taxing District? onHas mp rty oction been requested If yes,state amount of deduction
in Indiana? ❑yes 0 No current r'?for ❑Yes 0 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 20 - 20 ' 20' 20
Signature of County Auditor . County Date(month,day,year)
e
.4/1.- k. ch ri ,, w� hSt� 7- 31-19
certify under the penalty of perjury that th bove and foregoing information is true and coned and that the applicant is a resident of Indiana and
owner,contract buyer of the aforementioned property on date application is filed.
Signature( Ne name)9 Date(month,day,year)
F resident address of applicant(number and sheet,phiSi slate,and ZIP code)
13 8 5. rH ndl is o n/, VA/tad-nib tlikr. 47670
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,thy,state,and ZIP code)
The penalties for perjury can include imprisonment up to tiro and a half years and a fine not to exceed 510,000.