HomeMy WebLinkAboutMortgage_Meny (12) "enter STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS unty Township Year
��'y:\1, FOR DEDUCTION FROM ASSESSED VALUATION
i:' ' 'h State Form 43709(R14/1-20) LACWI 41111bSt1261:4 21)2C1
.4 :re Prescribed by Department of Local Government Finance
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File Mark
INSTRUCTIONS: To be filed in person or by mail.
Form iled with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. County Auditor
Must be filed or postmarked with the County Auditor
❑ County Recorder
See reverse side for additional instructions and qualifications.
Appli t(ow__n/er or contract buyer-see re nctio on reverse side) n ^ ,�
I i cJi(/Q.S 1l , `tla. /a ///yl- /M
Taxing Di trict ey number/legal descriptio Record number Page number
g a .6st 4 2 /g.•5 .9D3-aD•le2-- 0,09 20211-3103
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant a sole
assessment date,current year assessment date,current year date of application legal or equi e owner?
/ 3/ 77D 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 rty in question:Annually Assessed
Real Property ❑ •.- :1 Assessed
M..ile'l ome(IC 6-1.1-7)
Name o o agee or contract seller
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Address of mortgagee r contract seller
oj 0
oa J �° 3
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OCR 0� ti01
Name of assignee or other owner or holc
Dl aver NO
Address of assignee(number and street, INsvv` oR
Does applicant own property in ny If I Card N O• deduction bee equested �Q ,State amount of deduction
other county :rty for
in Indiana? ❑Yes No sear? es ❑TGo rr\8
A person is not entitled to this deduct _ ige or contract indebtedness that is recorded in the county
recorder's office(including any home equity line or cream 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
Signa o County Auditor Coun Date(month,day,year)
:��h— /0 - Q—2c 2C
I/ e certify under t e p alty of perjury t the above and foregoing inform ion is true and correct and that the applicant is a resident of Indiana and
tiawle
er/contract buyer of the aforemention property on date application is filed.
Signatu owner's full name) Date(month,da,year)
Full resin ent dress of a?ai
lican (number nd street city,sta nd ZIP ode)
A9Z (1-. // �l/ S7 2I/ j4,7c,37
Person authorized by duly executedPower of Attorney or by I 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$10,000.