HomeMy WebLinkAboutMortgage_White (2) _r,-n„� STATEMENT OF MORTGAGE OR CO Township Year
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;e FOR DEDUCTION FROM ASSESSED Vi
State Form 43709(R14/1-20) c77,3O40.,:',..!!,s
� Prescribed by Department of Local Government Finance D U
ieis . Drawer NO
File Mark
INSTRUCTIONS: To be filed in person or by mail.
Form filed with: •
Filing Date: Form must be completed and dated in the calendar ye Card NO �GL.County Auditor
Must be fled or postmarked with the County Auditor of _ /�'
located on or before January 5 of the calendar year in ❑ County'Recorder
•
•
See rever ide for additional instructions and qualifications. //
Applicant erOrco tract uyer-seerestri ' n ersesi )
QISCa1LIA
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er/ IdescnRecord number Page number
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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,ofapplication - legal or egeable owner?
1,/ 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
Real Property III Annually Assessed u
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller ,7)
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Address of mortgagee or contract seller(number andet,city,state,and d ZIP code)
Name of assignee or other owner or holder of mortga e
.0., or 70 di4 S—g ,01.5 .
Address of assignee(number and street,city,state, d IO.e)
'
Does applicant own property in any If yes,what county? What Taxing District? 'Ha this deduction been request'.s I yes,state amount of deduction
other county on.property for ,
in Indiana? ❑Yes ❑No current year? ❑Yes , o 4
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebte•.;l''s hat is -corded corded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's ofice)that is the b sis for e,t ct,n
COUNTY AUDITOR , FAQ
Deduction approved in the amount of: C/
20 20 20 20 20 , esO•vC ,,,� 10e0 20
Signature C ty Auditor • County 0- (md at/ttday,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applican s resident of Indiana and
owner contract buyer of the afore entioned property on date application is filed.
Signat own r full na e) Date(month,day,yea
e7/281-
F.I r- i en re sr enberan reef city,slat and I cod
-Ai Cte5• L. -0/1 1921 0
•erson authorized by duly execut Power of Attorney or by IC 6-1. 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$10,000.