HomeMy WebLinkAboutMortgage_Johnson (40) B STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE
=Aa FOR DEDUCTION FROM ASSESSED VALUATION I ; -
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State Form 43709(R14/1-20)
Prescribed by Department of Local Government
43414 ❑ County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where -'%)
located on or before January 5 of the calendar year in which the property taxes are tgl,roDeObic9GMYeTY AU D I ra County Recorder
See reverse side for additional instructions and qualifications.
Applicancl
nerorcontract buyer-seetrictions on r erserse side)
Toxin rict , Key number/ egal description Record 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 of ap lication legal or equitable owner?
5 c2 oo 0 ❑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 En)lperty in question:Annually Assessed
eal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
F-7 F .c.i J 0_J2- 6( /_ A• ,,__/() PitAs- r--s .
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) if
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Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code) y
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Does applicant own property in an If yes,what county? What Taxing District? ‘A..._other county '
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in Indiana? ❑Yes o
A person is not entitled to this deduction unless the person has a balance on the person' my
recorder's office(including any home equity line of credit that is recorded in the county n �-v P�
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'COUNTY AUDITC
Deduction approved in the amount of:
20 20 20 20 - D o 0 — D V�
Signature of Co my Auditor s County
I/We certify under the penalt of perjury that the abo e a oregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer o e aforementioned property on ate application is filed.
XSigna e(owner's full na Date(month,day,year)
/ ull resident addr ssofof applicant(number and street,city,state,and ZIP code) (,J
A 2-7 U 3 r li- Q 0 s® rVit 4- j O h '/,a- - L 7 LI
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 oeriury can include imprisonment uo to two and a half years and a fine not to exceed$10,000.