HomeMy WebLinkAboutMortgage_Burcham STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R14/1-20) FiLhst) 0 21 2020
Prescribed by Department of Local Government Finance
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File Mark
INSTRUCTIONS: To be filed in person or by mail. NOV 2 2 2021 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 co nt.y h-f• tit4ogrty4,7
located on or before January 5 of the calendar year in which the property ...4 -..9 [1] County Recorder
I SON COUNTY AUDITOR _
See reverse side for additional instructions and qualifications.
Applicant(•)vner or contract buyer-.szleirestrict? ?revere side) k
a_efr- CZ, e2-e.
Taxi AIP istrict I Key number/legal description Record number Page number
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Asstised value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the a t the sole
ass-ssment date,current year assessment date,current year date of application legal or able owner?
e a 0 O Yes Ell No
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If no,what is his/her exact share of interest? If owned with someone other than.pouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
Ull-fLreal Property ri Anauall -ssed
(IC 6-1.1-7)
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Name of mortgagee or contract seller E ....._ .._______
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Drawer NO... ..... ... ....
Name of assignee or other owner or holder of mortgage
55 ........
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Address of assignee(number and street,city.state.and ZIP code) Card NO. .............
Does applicant own property in any If yes.what county? What Taxing District? Has —.„.,,,e.teo If yes,state amount of deduction
on property for
rrnnerdicaonuan?ty 0 Yes No current year? Yes 0 No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or c n ct 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 tha 's the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20
20 0
20 T-- 20
Signature of Coun)y Auditor County Date(month,day,year)
2.14L"eer):4 30V\
I/We certify under the penalty of perjury that t e a ve and foregoing information is tr e nd correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
, j Signatiod.owner's( na e) Date(month,day.year)
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r.1 II reside. -ddres.of a•iilic.nt(nuiieryndfreet.city s te,and ZIP cod )
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I •il;i ' 5:. _
-erson authorized;iy duly eXe'ted Power of Attorney or by IC 6-1.1-1 -O. Date(month,day year)
Address of authorized person (number and street.city state.and ZIP code)
The penalties for penury can include imnrisonment uo to two and a half years and a fine not to exceed$10,000.