HomeMy WebLinkAboutMortgage_Martin STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
iii FOR DEDUCTION FROM ASSESSED VALUATION
State Fomn 43709(R12/6-16) Gibson Haubstadt
` Prescribed by Department of Local Government Finance is ' •—:a
INSTRUCTIONS: _/±_I:.h •
To be filed in person or by mail. I Form filed with:
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought E r O
Must be filed or postmarked with the County Auditor or County Recorder of the county where the properly f 1, my Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly Must file with the County Auditor of the county
where the properly is located during the tweke(12)months before March 31 of each year the deduction is sa/4yt .
See reverse side for additional instructions and qualifications. .TIHIGf
Applicant(owner or conwacf buyer-see restrictions on reverse side) G I BSO N COUNTY AUDITOR
James M. Martin
Taxing District Key number/legal description car Pe r C1
Haubstadt 26-23-06-103-000.535-009
Assessed vane of real propeny as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpa' as of Is the applicant the sole
March 1.current year March 1,current year date of app4/rs��./.CZ '7/4/• ,\ legal or equitable owner?
/ "� Qv () 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. Is the property in question:Annually Assessed
[7] Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or convect seller • •
—� F Li R\C1r tC o.�n\ Ac- / y/Jppy�y/y�
Address 9) �control {(number and street s and ZIP-code)' 1\/- S In-Chi- s-3 0 I w rs
Name of assignee or other owner or hobaerJof, mortgage
Address of assignee(number and sheet,city,state.and ZIP code)
Does applicant own property in a9/ If yes,what county? What Taxing District? 1 Has this deduction been requested 1 If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes La No current year? L.,/Yes ❑No
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 I 20 20 20 20
Signature of County Auditor County Date(month,day.year)
I/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.
Sip'owner's Ml name) ( . I Date(month,day,year)
.....t....2 ?u.
/a/3/iy
F," • ent address of applicant(number and street,city,state,and ZIP code)
411 S Bradley Dr., Haubstadt, IN 47639
Person authorized by duty executed Power of Attomey or by IC 6-1.1-12-0.7 Date(month,day.year)
Address of authorized person (number end sweet.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.