HomeMy WebLinkAboutMortgage_Blanton *Fq STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESSo�'nt , i'o ns Year
4 ` FOR DEDUCTION FROM ASSESSED VALUATION
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1'.t L ., State Form 43709(R14/1-20)
'- --v Prescribed by Department of Local Government Finance
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NOV 1 3 2(120llark
INSTRUCTIONS: To be filed in person or by mail.
Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. �'f III County Auditor
Must be filed or postmarked with the County
Applicant(owner or contract buyer-see restricti s on reverse side)
Taxing District ` Key n mber/legal description Record number Page number
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as o Is the applicant the sole
assessment date,current year assessment dal"-` current year date of application legal or equitable owner?
60 o eV 0 ❑Yes III 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: I t roperty in question:Annually Assessed
In Real Property ❑Annually Assessed
— __ __—_ — — Mobile Home(IC 6-1.1-7)
7 Name of mortgagee or contract seller g % Z/ jay 1-)
Address of mortgagee or contract seller(number and street,city,state,and ZIP cod,
a- 495.
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code) 7//Ig 7Z( K0 If,,I A.
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? Ill Yes o 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)
II We certify under the natty of perjury thatthe ve 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/ dateda application is filed.
` Sig ture(owner's f na )^ jel Fv/0",
�/e 17 _ , Date(month,day,year)
'�`( u resident a dressof p(number and street city,state,and ZIP code) / K/ /—/� CO///
Person authorized by duly executed Power of Attorney 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 u,o to two and a half years and a fine not to exceed$10,000.