HomeMy WebLinkAboutMortgage_May (7) . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
A( �;: State Form 43709(R14/1-20) G_0� O22 2i02Z
-. o Prescribed by Department of Local Government Finance J
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 year in which the property taxes are first due and payable. County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owr or contract buyer- strictions on reverse side)
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r Ta D' trict V Ke n b r 71 al desc' r 2.5 Red number Page nurpe r
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the ap li nt the sole
assessment date,current year assessment date,current year date of application legal or q table owner?
ift � Yes ❑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: I e property in question:Annually Assessed
Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(numb and street,city,`)er state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP cod.
Does applicant own property in any If yes,what county? _ ) ested If yes,state amount of deduction
other county ❑ D I aw et' i O... 0�
in Indiana? Yes ❑No IJ No
A person is not entitled to this deduction unless the perso, 2 nbtedness that is recorded in the county
recorder's office(including any home equity line of credit I Card NO. '/. 1 basis for the deduction.
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signatur County' to2� //�� County k� Data( oni clay,year)
2 at -1- 0
Irtify under the penalty of perjury that the above and foregoing information is rueand correct and that the applicant's a resi nt of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
ifi,,\ \ Signature( ner's full name) Date( in,riarlLLl,_
l Full re id ddre pplicant(number and street,city fate,and ZIP code) 1\t
iy,t
L \ S C — V — '
Pie .on authorized by duly executed P er 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.