HomeMy WebLinkAboutMortgage_Johnson (5) ,* _ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'`%<<a FOR DEDUCTION FROM ASSESSED VALUATIONt -7-,- I,,,
County Township Year
' State Form 43709(R14/1-20) Pe . i 26 urvQ
.
reu-,-* Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS: To be filed in person or by maiL DEC 2 2020 Form filed 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 or County Recorder of the county where t = •roperty's
located on or before January 5 of the calendar year
Ta District Key num r/legal description Record number Page number /
xin0e. d 4 . oZ 6 -i g-/ g -3O - b 0a g ,S / 'O ),6 --O X O 3 g-5'S
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 •.itable owner?
/ / !�/ o f c *� es ❑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 Is the property in question:Annually Assessed
LWM'S.. t Dr r,ort.. =.orn.muu_il,cecotad
1-7)
ame of mortgagee or contract seller t 0
( ty,s e, ZIP code)
Address of ort gee or contract seller number and street,ci , f `
Drawer NO ✓
Name of assignee or other owner or holder of mortgage _—
Card NO• •••.� 55
Address of assignee(number and street,city,state,and ZIP code)
l
Does applicant own property in any If yes,what county? What Taxing District? Has this deducti n be requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes V.NO current year? es ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or c tr t 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 C unty 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(owner's full name) Date(month,day,year)
Full resident address of applicant(number and street,city,state,and ZIP code)
L(0 l Ai Hu l t S'f, Fort f3 f-a rc k T�/ 4176 z-(52
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 nenalties for neriury can include imnricnnment un to two and a half vearc and a fine not to erreerd Ain nnn __