HomeMy WebLinkAboutMortgage_Ball STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
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Wi FOR DEDUCTION FROM ASSESSED VALUATION
l7� State Form 43709(R13/10-15)
,., i 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 properly is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. 0 County Recorder
2) Mobile I 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.
Appl wnerorr contracttr+ buyer-see restrictitions(�on reverse(� side)
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Taxing Dis Key number/legal description Record number Pa a numbb
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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 application (56, legal or equit le owner?
Ic l Q Yes ❑ 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: Is the roperty in question:Annually Assessed
O'Real Prope s .-Or ' ,-IyAssessed
' e Home(IC 6-1.1-7)
Name of mortgagee or contract seller
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Address of mortgagee or contract seller(number and street city,state,and ZiP code) 6 q o\g
Name of assignee or other owner or holder c ®� 1.
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Address of assignee(number and street,cif) i v141'1 l
Does applicant own pr rty in any If yes, eduction been requ 3�tsdS Ifes,state amount of deduction
other county t� r for /
in Indiana? e5 ❑No q _ sG Ly'Yes ir? ❑No
A person is not entitled to this deductior I a or contract indebtedness that is recorded in the county
recorder's office(including any home ec tfce)that is the basis for the deduction.
Deduction approved in the amount of:
20 20 20 20 . 20 ' 20' 20
Sig ture of County Auditor CoLt
• Date(month,day,year)
ci..¢-u) .L. b�• 1 -c Q-- \
I/We certify under the penalty of perjury that'the e and foregoing information is true and correct and that the applicant is a resident of Indiana and
pwner I contract buyer of the aforementioned property on date application is filed.
Sig lure caner' fu am Date(month,day,ye
I vJl lam -alp-\`A -
Full res ent addr of a licant mber nd street ci state and ZIP code)
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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 oenalties for perjury can include imprisonment LID to two and a half vests and a fine not to exceed S10.000_