HomeMy WebLinkAboutMortgage_Miller (27) ' ►. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
, `.= FOR DEDUCTION FROM ASSESSED VALUATION
• State Form 43709(R13/10-15)
i d 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 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)
1.1 PS\ Rae t C., fn., 1 I t°c- .
Taxing District Key number/legal description Record number Page number
5\''1 (Le. a(i2-Ii- I a -a01 -000. L - QA_ 2o2_0 548
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 legal or eceable owner?
4i C.1311 O 0 LE—Yes ❑ No
If no,what is his/her exact share of interest? If owned with somedne other than spouse,indicate with whom
If name on record is differentthan that of applicant,indicate below: Is thegaperty in question:Annually Assessed
eat Property 0 AnnuallyAssessed
• Mobile 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 e) a ,,
Name of assignee or other owner or holder of mortgage D I•a w C i O FE C
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Address of assignee(number and street,city,state,and Card Nr �O. O� 0 ,`
GIBgO --�`` fAv ty�
other ty applicant own property in If yes,what count �J/t/ 'a proips property
fortion-,been req t >)r/e ate amount of deduction
in Indiana? ❑Yes o 3 !l\J urrent year? L�'Yes ❑No �0I OR
A person is not entitled to this deduction unless Ili mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity line a girder's office)that is the basis for the deduction.
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COUNTY AUDITOR
Deduction approved in the amount oft
•
20 20 20 20 • 20 ' 20' 20
Signa re of County Auditor County Date(month,day,year)
I/We certify under the penaltyof perjurythatvd foregoing information is true and correct and that the applicant is a resident of Indiana and
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owner/contract buyer of the afor enti roperty on e i*= o• filed.
Signature owner's full name) Date month,day,year)
Full resident address of appr nt mber and street city,state,and lIPcode)
/b5 Si Pt KG 1J ST. l%/,r.�Ly[/5 / 4— 1 /Z/
Pe n authorized by duly ecuted 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 nenalties fnrnerfury ran include imnrt'nnment min twn and a half veata and a fine not in exceed. 10-000-