HomeMy WebLinkAboutMortgage_Miller (16) .e'.. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDI•F(Lo n i Township Year
e '-;'`,`i FOR DEDUCTION FROM ASSESSED VALUATION y� t`�/r/�
'.,r•� t State Form 43709(R14/1-20) v 00 et �-`
��-i„- // Prescribed by Department of Local Government Finance MAR 3 0 2022
File Mark
INSTRUCTIONS: To be filed in person or by mail. �`"i �. Form filed with:
Filing Date: Form must be completed and dated in the calendar year for which the deductiorn f�°lbflgcn t iind.) I7Q County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of th fA4t,lfecg1l/bTettolllaityl i O R L'LJy_
located on or before January 5 of the calendar year in
Applica t(owner or contract buyer-see restrictions on reverse side)
axing District Key number/legal description Record number Page number
.6 --19- 3 / - 3o/ _ oao. a-SY-oo9 .2d, g5'0
ssessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applic nt the sole
assessment date,current year assessment date,current year date of application
legal or ble owner?
l 00-//✓Foo Yes ❑No
If no,what is his/her exact share of interest? If owned with someone otth l/
r than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: 1 property in question:Annually Assessed
e/
Name of mortgagee or contract seller
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Address of mortgagee or contract seller(number and street,city,state,and ZIP code) llljjj �f`� t/��
Name of assignee or other owner or holder of mortgage ter( „! — /50
Address of assignee(number and street,city,state,and ZIP code) U)C/�
Does applicant own property in y If yes,what county? What Taxing District? Has this deduction b requested If yes,state amount of deduction
other county r �,i on property for ❑
in Indiana? ❑Yes IL1 No current year? es No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or c t 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)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County Date(mo h,day, ear)
I/We certify under the penalty of perjury that the above and foregoing information is t u and correct and that the applicant i a resi ent of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
" V Si wn s full name) Date(mH
year) v.,
.
re ' ress of applicant(number and street,city,state,and ZIP code)
c2o6. rz,1/>tt' _Cr 7/4/16"S/3•7c/r—z'zg763-(
Person authorized by duly executed Power of 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)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.