HomeMy WebLinkAboutMortgage_LLC (21) . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
:r..- TM; FOR DEDUCTION FROM ASSESSED VALUATION
'• State Form 43709 R13/10-15
* ,_,a , Prescribed by Department of Local Government Finance gibcS(r2_, VI ncar u r 1,
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 properly 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)
e� ocile.s1p kJ1 / Li
Taxiogpistrict Key number legal des vi.tion Record number Pagenumber
LVrineekoru 24--/1-/2- ./-vo3,AP/9-Daft 20 20 s'2
Assessed value of real property 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?
<5 700 DD° Yes 0 No
If no,what is his I 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: s th property in question:Annually Assessed
Real Property 0 AnnuallyAssessed
V
Name of mortgagee or contra eller 1..
Address of mortgagee or contract seller(numb ndSTieet city state,and ZIP code) ,- ` 5
10
Name of assignee or other owner or holder of mortgage -8
Address of assignee(number arDrawer NO -(Oc'
o
v�m1
Does applicant own property in a Card NO. Y(/�)(9 ,ing District? Has this deduction been requested to amount of deduction
other county on property for , e,e
in Indiana? ❑Yes ❑I current year? ❑Yes LJ
A person is not entitled to this 5 ice on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including an ed in the county recorder's office)that is the basis for the deduction.
:OUNTY AUDITOR
Deduction approved in the amour,-.
20 20 20 20 • 20 ' 20• 20
Sign r of County Auditor , z County Date(month,day,year)
1/ e certify unde th penalty of perjury th the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
ner/contract buyer of the aforementione property on date application is filed.
y,...Signature s 1 name) Date(month,day,year)
€1/1
Full address o a ica (number and fly,state,and ZIP code)
0 S. t4, -- k/tc..fi,A r - r 4176070
Person authorized by duly executed Power of Attomey 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 for perjury can include imprisonment up to two and a half years and a fine not to exceed S10.000.