HomeMy WebLinkAboutMortgage_Roth .9E r,� STATEMENT OF MORTGAGE OR CONTRACT INDEBTE S
".- \, my Township Year
-. mil ), FOR DEDUCTION FROM ASSESSED VALUATION
"i,, ,,i E I, State Form 43709(R14/1-20) )''.' '�='f Prescribed by Department of Local Government Finance F 01, W Z l
,EB File Mark
INSTRUCTIONS: To be filed in person or by mail. 1 2
O�r' Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which theal ' e t. County Auditor
Must be filed or postmarked with the County Auditor or County Recorder o itt ro�p�erty is
located on or before January 5 of the calendar year in which the property taxes ared'tijil /e. County Recorder
irOR
See reverse side for additional instr ions and qualifications.
Appli ant ifro r ct buyer-s res(ricti ns reverse sid
T in trict T, 'o
9 ,> Key nvnber gal description Record number Page number
Assessed va ue of r property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the s le
assessment date, u ent year assessment date,current year date of application G legal or q ' ble owner?
6�07�, 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 ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mort agee or tr ct s Iler /
.-/-%/1 '" 146°
Address of mortgagee or tract seller( tuber and street,city,)and code)
Name of assignee or other owner or h r mortgag 41c75.---z^
�� ‘_/ 9 /�pi
Address of assignee(number an str et, ' , tate,and ZIP code)
Does applicant own property in any If yes, —" — __ - '- -ction ee requested If yes,state amount of deduction
other county
in Indiana? ['Yes ❑No r es ❑No
A person is not entitled to this deductior it'on ct indebtedness that is recorded in the county
recorder's office(including any home ec Drawer NO. .GiCJ : )th t is the basis for the deduction.
Deduction approved in the amount of:
Card NO.
20_ 20 20 20
Signs re CduntyAudit I County I Date(month,day,year)
/ela 4) )
I/ e 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
ner/contract buyer of the aforementioned property on date application is filed.
Signature(ow -s full name) Date(month,day,year)
Fu si� dint address of applicant(number and str � state,and ZIP code) t n , /'
547,576 (7/ , / ge..4 Ay)
Person authorized by duly executed Power f 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) it
st
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.