HomeMy WebLinkAboutMortgage_Koch Jr ,, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
7�� �s FOR DEDUCTION FROM ASSESSED VALUATION r�/_/�
)1. State Form 43709(R14/1-20) G\`v✓'‘ 02�- �'V�
�,e • Prescribed by Department of Local Government Finance Jv
File Mark
INSTRUCTIONS: To be filed in person or by mail.
Fo m 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 of the county where the property is
located on or before January 5 of the calendar year in which the property taxes are first due and payable. ❑ ounty Recorder
See reverse side for additional instructions and qualifications.
Applicant owner or contract byiyer`see t` do son rests. a side) O�
Applicant
^(� V J\Y
Taxing Dist Key nu er/legal de lion-� ,2 —r� 0 0— (� & I ^ ` Re_,prd nQum�er� Page nu �
2� _ c� b L
Assessed value of real property as of Mortgage/Contract indebtedness unpaid aii Mortga a Contract indebtedness unpaid as of Is the pp' nt the sole
assessment date,current year assessment date,current year date of plica' )/—, legal o uitable owner?
Yes ❑No
If no,what is his/her exact share of interest? If owned with s eone other than(spouse,indicate with whom
If name on record is different than that of applicant,indicate below: I e property in question:Annually Assessed
Real Property ❑Annually Assessed
1111.. 4--------1 Mobile Home(IC 6-1.1-7)
Name of mortga a or contract seller_
Address of mortgagee or contract seller(number and street,city,state.a ZIP de)
I CE9D-r---4.
Name of assignee or other owner or holder of mortgage S E P 1 4 2022
Address of assignee(number and street.city,st ZI ode)
Does applicant own property in any f y t n What(1/16t UNTY ytpast.,.tt, uction en requested If yes,state amount of deduction
other county c"✓' ❑
in Indiana? ❑Yes current year?r Yes No
A person is not entitl o s d ct, nless the person has a balance on the person's mortgage o cont ct indebtedness that is recorded in the county
recorder's office ' I ' g h e equity line of credit that is recorded in the county recorder's office)tha is the basis for the deduction.
COUNTY AUDITOR
DedVI)-I%in e a ount of:
20 20 20 20 20 20
Signature of ounty A_ uditaf Xt �,� ( ')
County Daten h,ray, za
I/We certify unr the ppenaallty of perju that the above an regoing information is trt a d correct and that the applicant i a re`ssi nt of Indiana and
owner/contract buyer of the aforementioned property n ate ap li on is
ig ure(owner's fullY,lct / y( Date(month,day,year)
Ful r sident address of applicant um applicant(num(/b'/ nd street,city,state,a Zl code
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.