HomeMy WebLinkAboutMortgage_Harvey (4) 4. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
C arty Township Year
A.:.:, �: FOR DEDUCTION FROM ASSESSED VALUATION /�1 I `
•= State Form 43709(R13/10-15) �bn �h I r , __1(�1 ok �2C
�'� , Prescribed by Department of Local Government Finance `�V 1U,y'�!i
+ens SV.2"
Li File Mark
INSTRUC7TQNS: r-
To be filed in person or by mail 03 O I3 Fo led with:
Filing Dates: 1) Real Properly::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.
nt(ow\ne con tr yer-see restriction n reverse side)
T • District ( Key number egad d crip n �J 3'-- P 11 Record number Pa err^um}�r
2 - -fl-20 o 001. a Ip Zd�0 V F�
Assessed value of real property as of Mortgage/Contract indebtednes pai as ,_.,I .- ontract indebtedness yr$ id as of Is the ppfppnt the sole
assessmentdate,currentyear assessment date,current year date of<ppi " legal liftable owner?
1_, ,000-- Yes El No
If no,what is his/her exact share of interest? `f •r-• ' 'r eOne othevthan spouse,indicate with whom
ff name on record is different than That of applicant,indicate I below �' Ir. 1 e property in question:Annually Assessed
Annually Assessed
• CtBSnN COUNTY AUDITOR eal Property 0 Mobile Home(IC i-1.1-7)
Name of mo gee or contract SCb.._ �1 '
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage Drawer NO c Qa0
Address of assignee(number and street city,state,and ZIP code)
Card NO.
Does applicant own property in any If yes,what county? What 1 ��)Q d If yes,state amount of deduction
other county kCQ l 000 c'�
in Indiana? ❑Yes 0 No ^ . ! to
A person is not entitled to this deduction unless the person has a ba '�3���(cd e C. 7ft tnc).(9 • rdness that is recorded in the county
recorder's office(including any home equity line of credit that is rec c t_lczyukt cif is for the deduction.
COUNTY AUDITOR 1
Deduction approved in the amount of
20 20 20 20 20 ' 20' 20
Signature of Coun u it County \.....) �� Dmonl day,yeah
r,(Jt'J1
I/We certify under the penalty of perjury tha a above and foregoing information is and correct and that the applicant is a resident of Indiana and
owner 1 contract buyer of the aforementioned property on date application is filed.
S'gnature(owner's full name),. c
Date(month,day, ear)
Z.�1-- 2.�
yil r ident i ress of a plicant bur rber and street;c' sta and ZIP code)
1 c ock.k U-\ - Din —
Person authorized by duly executed Powet of Attorney or by IC 6- .1-12.0. 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$10,000.