HomeMy WebLinkAboutMortgage_Kell (2) 0,.•4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
County Township Year
' ,` .*. FOR DEDUCTION FROM ASSESSED VALUATION
'.:,.. 9= State Fonn 43709(R13110-15)
% ` <" Prescribed byDepartment of Local Government Finance
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INSTRUCTIONS: File Mark
To be filed in person or by mail. n rr TT pp �((��11 Form filed with:
Filing Dates: 1) Real Properly:Must be completed and dated in the calendar year for which the 1IbdLc6on is`sk aht
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is • aunty Auditor
located on or before January 5 of the immediately succeeding calendar year. ►r County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the county
where the property is located during the twelve{12)months before March 31 of t r� imught
}ee reverse sid for add'"oral instructions and qualific ons. G I B S O of
�t ..: ' 1.1 n antra b r-see,strictions on a si
• i Key number!I ga 'ptioq I 0 'h Record mbar Page number.—
WAY
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Assessed value of real prope a 1 Mortgage/ tract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assess �u¢entylar�,/� date of application legal or equitable owner?
(,�j(J l/(/^��/)C/VJT/vl ❑ Yes 0 No
If no,what is his/her exact share of interest? / If owned with someone other than spouse,indicate with whom
tf name on record is different than that of applicant,indicate below: ( Is the property in question:Annually Assessed
0 Real Property 0 Annually Assessed
• / Mobile Home(IC 6-1.1 7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and street, l state,and ZIP code)
al-0/ 3 — o233 /
Name of assignee or other owner or holder of mortgage
Drawer NO
Address of assignee(number and street city,state,and ZIP code)
Does
countyicant own property in any If yes,what county? What Taxing District? Has property
is deducother Card N O
in Indiana ❑Yes 0 No currrent y a for ❑Yes ❑No I
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 a 20 20 ' 20' 20
Signature o n A 'or, ,ni/I� y CountyA Date(maim, y,ye / 9
,/A��1�� 1 �'J�J�U l
I/We certify under the penalty of perjury that the<; r:act) information
foregoing is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned pro•- e application is filed.
r ature(owner's fuit name) Date onth,d earl
inLd Ni g di-4.U1---f2.— — etd- 7 ' 9,--e. 7.7/
CI resident address of apglicant(number and street,city,state,and ZIP code)
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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,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.