HomeMy WebLinkAboutMortgage_Washburn STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
'iist�ri.i,,, FOR DEDUCTION FROM ASSESSED VALUATION
f State Form 43709(R13/10-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. Form 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 0 County Auditor
located on or before January 5 of the immediately succeeding calendar year. 0 County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is 1 during the twelve(12)months before March 31 of each year the deduction is sought
See reverse sid for additional instructio and qualifications.
Appli (ow or contract buyer- re ictions revs s �
Taxin ' n �!/—/f/Key nu /legal description ` 7Ur xi / yo
Asses value of I property a Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the a�
pa plipnt the sole
acca nt dat rrent year assessment date,current year date of application i legal or equitable owner?
0/CCA/ ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other thail spouse,indicate with whom
if name on record is different than that of applicant,indicate below: Is the roperty in question:Annually Assessed
sal Property 0 Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller '/--r\.�y2 -
ed
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
Does applicantr A own property in any If yes,what county? What Taxing District? Has on this deduction been requested If yes,state amount of deduction
in Indiana? ❑Yes 0 No current year?r ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebte e at rec d 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 bast or ducti 1
AUDITOR COUNTY A R
N U O
Deduction approved in the amount of: OC r
l 18 20/9
20 20 20 20 20 20
GieS0
Signature /'myAu¢Ror County %goy
1/We certify under t e penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signatur II n me) Date(month,day,year)
6-1'
Full resid t address of applicant(number and street,city,state,and ZIP code)
-f z ( 5 *2.,• 4/ G>✓r,✓sV;€ -2 ' 117
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.