HomeMy WebLinkAboutMortgage_Ray (2) 4.. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
=% t FOR DEDUCTION FROM ASSESSED VALUATION
�=� �'f�';f= State Form 43709(R13/10-15) CA5
ky� 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 ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
• where the properly 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 contract buyer-see restrictions on reverse side)
(1;
Taxing District Key number/legal descrip on U R num r Page number
frce4O .
ss ale- I. -1g- ( -CCO-\. i- OQR- �tq ti.S^g
essed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application CO legal or equitab owner?
c* l.g l y��l , es ❑ No
If no,what is his/her exact share of interest? If owned with somedne other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is thvroperty in que -tom Annually Assessed
'IrReal P •atip 'I .1"nuallyAssessed
1
Na e of mortgagee or contract seller 1, t6 'bile Home(IC lri.1 7)
8..
Address of mortgagee o tract seller(number and street;r'lte,an kP code) O �Q
Nw
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city state,and ZIP code) -J)l G�041 1 .
OS
Or1
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? El Yes El 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 2d 20 20 20 ' 20' 20
Sig Lure or County Auditor C unty Date(month,day ear)
I/We certify under the penalty of perjury that t above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner l contract buyer of the aforementioned property on date application is filed.
Signature(ow / e) Date(month,day,yew)
Full res d r of a pli tier I and ZIP code)
Per authonzed(� by d executed Powerl of Att mey or by IC 1.1-12-0.7 ���n C� Date(mo�rthi.di y,year)
—1 \ ' \ f /11---C� �Y[-',h`7C A61� C J�
ddress of authorized person (number and street,city,state,and ZiP codm
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000. "Iirs.„