HomeMy WebLinkAboutMortgage_Jenkins (11) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
-, _ FOR DEDUCTION FROM ASSESSED VALUATION w
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„ 7`s State Form 43709(R13/10-15) • S k1kit • V.
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< Prescribed by Department of Local Government Finance " l'
File Mark
INSTRUCTIONS: ; NOV 2.2 201a 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 p erty is ounty Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobr&e/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 each year tffe o Is' a A OR —
See reverse side for additional instructions and qualifications.
Applicant( erorcontract buyer-see restrictions on reverse r e)
Taxiist' c Key number/legal des lion
Record number Page number
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Assessed value of real property as of Mortgage 1 Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
,vAt.m5mentdate,current year assessment date,current year date of application legal r itable owner?
(t5' 000 . Yes ❑ No
If no,what is his I her.exact share of interest? If owned with sometne othef than spouse,indicate with whom
if name on record is different than that of applicant,indicate below: RReal
property in question:Annually Assessed
Is
Property 0 Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
bat
J
Address of mortgagee or contract seller(number and street city,state,died ZIP code)
Name of assignee or other owner or holder of mortgage
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 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)
S- ,Smi' �6; l 1- 2,r- 19 _
1/We certify under the 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_
\/Sign M'a(owner's full na e) Date(month,day,year)
Full res tINd of p ticant( umber n -, city,state,and ZIP code)
334 .� ,dz a -1 (01
Person authorized by duly executed Power of Attorney IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state,and ZiP code)
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