HomeMy WebLinkAboutMortgage_Clore (4) ,_:,. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
`* FOR DEDUCTION FROM ASSESSED VALUATION
FILED
*,'' 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. DEC 3 1 2019 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 wh the pro ed 's 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 ty
where the property is located during the twelve(12)months before March 31 ofe-�t' --!t tiiResbiWirOR
See reverse side for additional instructions and qualifications.
Applican P . 'er contract buyer- restri�tjons on re Terse side)
Tawn D' 'd Key number/legal description Record nu er ber
` g6 - 06— i6 — Lioo -000 . (279_ 0f -7 ?�\c 21
Assessed value of roperty as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
1_. 9 17 ❑ 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 property in question:Annually Assessed
0 Real Property ❑ Annually Assessed
' Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller irr
T EGLI
Address of mortgagee or contract seller(number and street city,state,and--
Name of assignee or other owner or holder of mortgage pc n JG• V'r)C /)d
Address of assignee(number and street city,state,and ZIP code) '6 J
•Does applicant own property in any If yes,what county? What es,state amount of deduction
other county
in Indiana? ❑Yes 0 No i current year? U Yes U No I
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)
I/We certify under the penalty of perjury that the above d foregoing information is true and correct and that the applicant is a resident of Indiana and
er/contract buyer of the aforementioned property on date application is filed.
Sign w r fu I n Date(month,day,year)
/fl
ul r i n f p can��itu ' ,state,and ZIP code) .
( g' ci cr ct i
ki (17 6 Y 7
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 penalties fornedury can include imprisonment un to two and a half vears and a fine not to exceed S10.001