HomeMy WebLinkAboutMortgage_Keller (3) @:: STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNEIF t.
I i....___
' I .,._l FOR DEDUCTION FROM ASSESSED VALUATION tin wns p Year
State Form 43709(R14/1-20) I son I 2020
Prescribed by Department of Local
Form filed with:
Filing Date. Form must be completed and dated in the calendar year for which the deduction is ht.
Must be filed or postmarked with the County Auditor or County Recorder of the cou y County Auditor
located on or before January 5 of the calendar year in which the property taxes are iii -a b eA DITO Li County Recorder
i
See reverse side for additional instructions and qualifications.
Apd;icant(o,•ner or contract btr -see restrictions on7-evere7side)ix- --7- --- - -----
4_rt-S2e—ec--1- ..etf
Taxing D;stect Key number/legal deschiption-- Record number Rage)1 number -I- /0 - 3 6, - if p a - p a 41 .3 e.5 .-e2ot i I a/
3 !
.....,
Assessed value eat property a- • Mortgage i Contract in-idebtedness unpaid as of IMortgage/Contract indebtedness unpaid as of Is the epic the so'-7-7
assessment dxt-.current yea' assessment date current yea- I date of application legal o. gable owner? I
Sr
lYes [-7 No
---If r-O.what is his I her exact share of interest? 1 If OwnedWith someone other.tan spouse indicate with whom
I 1
__ ___„_........... __
on record is different than that of applicant.indicate:,booZ7
Is th roperty in question:Annually Assessed i----
_
.._. Real Property Ej Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract sere"
LA) th _ _
kE, .._
.
1347---
Address of mortgagee or contract seffer(hureber and street.cif/ state.and ZIP codiA-------
/
Name o`assignee or other owner or holder of mortgage
Add ra ress ossignee(norniffier and street city state and ZIP code.) _
Does applicant ow,property in any If yes v.'bat county', -Rata!TaxingbishiTdt? I Has thistiled:JCL i een requested If yes,state amount of darzu,cc,.
rritilnerdica°r•uarP P Yes FL-1,1>e5.- I I on property for
I current year? Yes [I No 1
.... _
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contra 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 he basis for the deduction.
........_
COUNTY AUDITOR
TO;iducher;app7O-yed in the amount of
r— •
6
20 I 20 20 ,
20 20--- T----
'...-.—
1 i
---i;
Signature.of County Auditor 1 County Dati h. / r)
I - 3-QV\
--Z.Z.2-- 2--i
__________ •
I/We certify under the penalty of perjury that the above and foregoing information is true nd correct and that the applicant is a re ident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
,e),(I:agnature per's Tuff n me.) -7
Date(month day year)
c!!r ant a- ress of applican7riumber aid street 7571ria-t and ZIP code)
90g7 S. 7 t9e) te,/, ef:f7i,,,e'vklizci le: _4,-
A) 117 4 6'5-- _
Re-son authorized by duly executed Power of Attorney or by IC 6-1.1-12-0 7 Date(month,day year)
Address of authorized persor (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 510,000.