HomeMy WebLinkAboutMortgage_Coleman (5) .ems t , STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
ds FOR DEDUCTION FROM ASSESSED VALUATION �`}o�aO
��1 State Form 43709(R14/1-20) ^ I b5on ��
Prescribed by Department of Local Government Finance 7WjIl.Se
File Mark
INSTRUCTIONS: To be filed in person or by mail.
Form filed 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
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Taxing District Key number./legal description Record number Page number
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Assessed 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 equitable owner?
i 00/000DPirg ❑No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
Qzal Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
N e of mortgagee or contrXact seller
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Address of mortgagee or contract seller(numb
Drawer NO...a_.a. ... FILED
Name of assignee or other owner or holder of r ( 1��
Card NO. 1u9 NOV 4 2022
Address of assignee(number and street,city,s ���C,
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been request
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other county on property for �,,�
in Indiana? Eves ❑No current year? t(yer ❑GtB ON COUNTY AUDITOR
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract 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(month,day,year)
Itc.) � G i h so n t 1/4/0)../
1/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/,contract buyer of the aforementioned property on date application is filed.
Signal a(owner's full ) Date(month,day,year)
Full resid �1 -of applicant(number and street, ity, ate,an /P code)
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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)
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.