HomeMy WebLinkAboutMortgage_Jacke a+` ; _ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
�— ; FOR DEDUCTION FROM ASSESSED VALUATION
' '.t ` State Form 43709(R13/10-15) 30 a(r111�1
�J`_I
`' ,., � Prescribed by Department of Local Government Finance .
INSTRUCTIONS:
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/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
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.
Appli (owner or contract u er-seerestrictionsop.reverse side)
arNq E arrvt L 3 ack.e
T ' Distri Key number/legal escriptio Record number pm
A Ac3-2,O--,3 , Soo-°Do 52S-oo ( . �ODD� -
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortga'e/Contract indebtedness id as of Is the applicant the sole
assessmentdate,current year assessment date,current year date of:ppli.. .• \to legal or equ le owner?
• Yes 0 No
If no,what is his I her exact share of interest? 1 ne with so :,•.ne other than spouse,indicate with whom
tf name on record is differentthan that of appli di km. • Is th roperty in question:Annually Assessed
Real Property 0 Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee r contract er 2)01AT0,041'1%
i
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or othe ire r Icier mgl*q ge O / 5 A SO
Drawer NO
Address of assignee(number and street 7 city,state,and ZIP code) D)
Does applicant own property in$hyF It ye tiEunty? What Taxing District T ,•,,,•• ite amount of deduction
other countyC a r Cl I�O•
in Indiana? ❑Yes 0
•A person is not entitled to th' the person has a balance on the 'recorded in the county
recorder's office(inq l i q ryr-04f that is recorded in the c _ .,., osw ueduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 . 20 20 . 20 ii 20' 20
Signature of County Audit. ^ County [TJ ,J]J ,t) Date(month,day,year)
I/We certify under the penalty of perjury that the above toregoing information is true and correct and that the applicant is a resident of Indiana and
t owner/contract buyer o he aforementioned pr•perry on date application is filed. DEC 1 12019
,,,..........p.. ,,....
Signature(owners full name) Date(month,day,yea
Full reside addr-" .•• n '"�,state, nd Z de)
t(nLl ;�—'� L — n,— gS6NI OUNTY AUDITOR
Person authorized by duly executed Power of Attbmey or by IC 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. •