HomeMy WebLinkAboutMortgage_Brines (4) 0 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS ' County Township Year
' 11= FOR DEDUCTION FROM ASSESSED VALUATION Q
,\:12-,..:i-�; State Form 43709(R13/10-15) Zo` \
Jd' Prescribed by Department of Local Government Finance •
INSTRUCTIONS: File Mark
To be Ned in person or by mail. Form filed with:
Filing Dates: 1) Real Properly.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/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.
Applicant(owner or contract buyer-see restrictions on reverse side)
S&Me 111 Qn v--.‘r �S •
Taxing District K mber/legal description Record number Page num er
,... u1— La-10--i— DeLA - LOoi - yQ- Cab 201ct 5116
Assessed value of real property as of Mortgage!Contract indebtedness unpaid as of Mortgage i Contract indebtedness unpaid as of Is the applicant the sole •
assessment date,current year assessment date,current year date of aQpIi 1 OD
0 CO legal or equity er?
A�6 O�ll es ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: .., r pr..erty in question:Annually Assessed
y P I -eaI Property 0 AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller € , p v,. ' i
Address of mortgagee or contract seller(number and street city, "=t- l n• ' ✓+'•d t
Name of assignee or other owner or holder of mortgage ®en '6�
sb
Address of assignee(number and street,city,state,and ZiP code) cc `�e01,9
. 4"'&0A •
Does applicant own property in an If yes,.what county? What Taxing District? Has this dedu If yes,state amount of deduction
other county ,L—�Nj on property for
El Indiana? Yes o current year? Y o
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract in e/?Jt rdp ess 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 fI4he deduction.
COUNTY AUDITOR
Deduction approved in the amount of.
•
20 \. 20 20 20 20 ' 20' 20
Sign r of County Auditor Co ty ate(month,day,ye
I,We certify under the penalty of perjury that e ab 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.
Signally (own s full name) / , Date(month,.day,year)
resideFull of applicant number and street,city,state,and ZIP c d
e \\
Person authorized by du execu ed Power of Attorney or y 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 forpedur,can include imprisonment up to two and a half years and a fine not to exceed$10,000.