HomeMy WebLinkAboutMortgage_Roblero .4 -.4.,. STATEMENT OF MORTGAGE OR CONTRACT INDEB& PrVES
..., Township I Year
./04:- .41p., FOR DEDUCTION FROM ASSESSED VALUATIONi... .......
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".:''''.:',.. State Form 43709(R14/1-20) n I 0 Ls I 25,, 2_z_H
Prescribed by Department of Local
% --CormThedWith: •
Filing Date: Form must be completed and dated in the calendar year for which the thedction is sougl . .
Must be filed or postmarked with the County Auditor or County Recorder ,fitlegh 604r is County Auditor
located on or before January 5 of the calendar year in which the propertxlmeeaCstatiTYariM-R 1 1 County Recorder.
See reverse side for additional instructions and qualifications.
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!Ap cent(owner or contract buyer-seestrtcttor2s en everse side
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,Taxi) istriok I Key number I legal description I Record number 1Pace number --
,iel_ig ,.
-Assessed value of real property as of. 1\alosrtgaispameeintCgarittLacctuinredr,ete4niess unpaid as of I 1.:11.oteritgoagaep.Iplciit,seaciitoranct indebtettnes unpaid as of In the pplic the so
assessment date.current year legal oi able odiner?
es No
Ifro.what is his/her exact share of interest? 1Towned with sorneone other than/spouse.indicate with whom
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'if name on record is different than that of applicant,indicate below — -— e/13
Is th e, roperty in question:Annually Assessed
. ) ,Real Property Li Annually Assessed
_ Mobile Home(IC 6-1.1-7)
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i NaMeof wort
iC itzeie-Cir contract seller
1 (1a,,,blezrreedt-
I Addre-Saof mortrgiiddee or contract seller(numher and street.city ate,.and ZIP codei _
1 NaMre'Of assignee,or other oiwner or holder cf mortgage
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11-AdMeSa of assignee(7-ridrober and sheet,city state and ZIP code)
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i Does applicant or property in any If yes what county? rtiVriat Taxing astrict?--- [Has this deduction been requested i I'yes.state amount of deduction --1.
)(iori,t Le icari,uarii2ty
LilYest'S 1 Ion property for r-..,Yes 1 current year? 1_1 Li No 1 I
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A person is not entitled to this deduction unless the person has a balance on the person's mortgage or cc " - -
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)I
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COUNTY AUDITOR
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iiDeductioni approved in the amount of: Drawer NO...AUth-\
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20 20
i 20 I 20 i \ 20
1 I
__I 1 Card NO. br(5-\
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sig,. 60,,ti cii-0, - ecuee,...42„ co,:b. ..3 4\ 1.
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I I We certify under the penalty of perjury that the above and foregoing information is tr e and correct and that the applicant is a resident of Indiana and I
owner/contract buyer of the aforementioned property on date application is filed. I
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Sionature(owner's fu!/n me) Date tejimth IDiy51. /2/(2_,,
IN\ ' 0:Afti\- 2-th-t0 y i
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i ;P-uli resident cidiess of applicant(number and street city state and ZIP cod ) ---
K ,LAT) L_Q-1 c•-- , •
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Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0 7 Date(month.day year)
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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 510,000