HomeMy WebLinkAboutMortgage_Cox ., STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
1- A FFOR DEDUCTION FROM ASSESSED VALUATION
: State Fort 43709(R13/10-15)
4. =---4 Prescribed by Departmart of Lo I Govern -r • r
INSTRUCTIONS: ilt File Mark
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property:Mus''a rr. d cn. t•din .t-ca 7 ar a i the deduction is sought
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is 0 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-se�restrictons on reverse side)
Pr Ptt� l L . x •
T ng Distnct Key number!legal description Record ber Pa a nu r
Vr•k is a� - ► cPul.-- uo3 - Ooi aR�-®a6 2 nu0 \ .
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage!Contract,indebtedness unpaid as of Is the applicant the sole
assessmentdate,current year assessment date,current year date of plication legal or equity le owner?4 l . 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 differentthan that of applicant,indicate below: Is the property in question:Annually Assessed
'eel Property ❑ Mobile Home ss 6-1.1-7)ed
•
Name of mortgagee o ntract setter
Pa 4--- I C cam► . J L- c -4m ILE
Address of mortgagee or contract seller_[number_andstreei.cilv_RfatP_and ZIP rndal_ �:P
Name of assignee or other owner or ho
?u/9
Address of assignee(number andstree Drawer NO ales •
• • ON Coy ,
Does applicant own roe man I T deduction been re ues ed ' 4 state amount of deduction
other county property,_,__,//y Card I\O. rty for ,—, q "r TiJR
in Indiana? ❑Yes L_�•!'ido :ar? Q)fes 0 No
A person is not entitled to this dedu v / 9 _ - 5 oL S 7 ge or contract indebtedness that is recorded in the county
recorder's office(including any hair office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of.
20 20 20 20 • 20 ' 201 20
Sig lure of County Auditor s C unty f Date(month,- day,yea
I/We certify under the penalty of perjur1,that ifs 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.
Signature(owner's II name) D to(month,day,year)
‘0.
... ..
�® t a dress of alp scant be and stint,city,state,and ZiP c` —�Y; `Tt/) n l
- ,
Person authorized by duly executed Power of Attorney or by IC 6-1. 07.3� Date(month,day,year)
Address of authorized person (number and street;city,state,and ZIP code)
The penalties for perjury can include imprisonment un to two and a half years and a fine not to exceed 510.000.