HomeMy WebLinkAboutMortgage_Lashbrook (3) <0.-FItt.k. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS CountyTownship
�� FOR DEDUCTION FROM ASSESSED VALUATION Year
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�'� .,,„). State Form 43709(R14/1-20) 7!/ .f/�/" �ribMeA 20 2
�• �i•' Prescribed by Department of Local Government Finance ��,,( l/ 1
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INSTRUCTIONS: To be filed in person or by mail. au ,,��
,N° m filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deduction is sought. /(,W ❑ County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the county where th ••-+
located on or before January 5 of the calendar year in which the property taxes are first due a 4.a �e J ounty Recorder
See reverse side for additional instructions and qualifications. ►r—t7i
Applica t(o i r or co tr t buyer-se r= o 'on reverse side) t
Ta *�i t ySttuber/legal description Record number Pa nu er
Q �;% —///3dUof- am A`969-Qal-7 X021 I
Assessed value of real propert 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 applic ' O legal or q able owner?
7 7� ,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 t property in question:Annually Assessed
y�Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
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Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee r r owner or older of m /
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Address of assignee nu r and street,city,state,an ZIP code)
Does applicant own property in any I If yes,whatrs"---^- _ :this deductio b,en requested If yes,state amount of deduction
other county V13 iroperty for
in Indiana? Yes ❑N Z�). 1 /� koolu •- ,ry) ant year? Yes ❑No
A person is not entitled to this t J J5r"' !J Aix rtgage or on ct indebtedness that is recorded in the county
recorder's office(including any er's officeth is the basis for the deduction.
Deduction approved in the amount VliSU—+
20 20_ ttg//�,,1 y /-p�a`-' _ 20 20 20
Sign ure f Cbunty Au ' �t , . i County \ Date(month,day,year)
I A- 6.)041-fi �o I lOv 2. 2 ,c7/02, 1
I/ certify under the penalty of perjury that the above and foregoing information is tru a d correct and that the appltednt is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signatur -(r*Oer's full namq) Date(month,day,year)
Full resident address of applicant(number and street,city,state,and ZIP code)
a2-1 L e0"- A-L16 q A+c=TON DJ L-r - 0
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 ti 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.