HomeMy WebLinkAboutMortgage_Harmon (3) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS CouTEE)) Year
FOR DEDUCTION FROM ASSESSED VALUATION
0.41> State Form 43709(R13/10-15)
4 Prescribed by Department of Local Government Finance
INSTRUCTIONS: MAY F a6 2Q
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 propertvl ou uditor
located on or before January 5 of the immediately succeeding calendar year. ounty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the county AuditorefiB Witt0U1\TY All ITOR
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)
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Taxing District Key number/legal description Re rd umbe pa a number
aco-Ia-m- I of -coo . ?1,03 - OQF e dd to
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?
/ 3 S/ 00o , oo El-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
Et Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
F:V ot-r1-sv i I e Tt°a ch�c c RC'.L(
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taking District? Has this deduction been requested If yes,state amount of deduction
other county � i.• on property for
in Indiana? ❑Yes I:A-No current year? ❑Yes ❑No
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 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 ner ) Date 7nth,da year)
ll/k_ bao
Full resident address of appli nt(number and street,city,state,and ZIP code)
3c u Li . L Ja I n lA -F S± I Pic n c e-1—o n , _� �t 7( 7
Person authorized by duly executed Power of Attorney orb 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 periury can include imprisonment up to two and a half years and a fine not to exceed$10,000.