HomeMy WebLinkAboutMortgage_Perkins (5) . q, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDr1 C(e-D Township Year
s* A FOR DEDUCTION FROM ASSESSED VALUATION O 2` , ��
State Form 43709(R14/1-20) J� "`
1', Prescribed by Department of Local
ht. aye County Auditor
Must be filed or postmarked with the County Auditor or County Recorder of the �$ �� ITOR County Recorder
located on or before January 5 of the calendar year in which the property faze
See reverse side for additional instructions and qualifications.
Appr nt(owner or contract buyer-see restrictions on verse side)
Taxi District f Key number/legal description Record number Page number
-/t�-a..d?J a 6-/`�- 3 5 - Sr o a - 00 A . 6,g cD _ o ,), y '� -
. —1- 1 8 2
A essed value of real property 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 application legal or q able owner?
(f.2 S o o o Yes ❑No
If no,what is his/her exact share of interest? If owned with someone other tlian spouse,indicate with whom
If name on record is different than that of applicant,indicate below: I Is the property in question:Annually Assessed
Name of mortgagee or contract seller _ -
, i-e--e,e- Drawer N O 2 O 2.2
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)Name of assignee or other owner or holder of mortgage Card NO. i. (S22-
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction en requested If yes,state amount of deduction
other county ❑ ^,,! on property for
in Indiana? Yes IjJ"V current year? es ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or co 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 the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of Co` r / County 1 Date(mont day,y ar)
I/We certify under the penalty of perjury that the abolr and foregoing information is and correct and that the applicant is a resid nt of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signature(owner's
7 ((owner's full name) �_, #/��,,77 {/-�'-- Date(month,day,year)
r
/ Full resident address of applicant(number and street,city,state,and ZIP code)
(/ -40 c2(n E L 3h...t.c_ ( -- 0A-n o 116Au_bn-facLt ,97') 4/7 CP 39'
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 S10,000.