HomeMy WebLinkAboutMortgage_Michel (10) I. \ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Count wns Year
e,. . FOR DEDUCTION FROM ASSESSED VALUATION State Form 43709(R12/6-14)
�i! Prescribed by Department of Local Government Finance
INSTRUCTIONS: A r pt�Rfo 15
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is my Auditor
located on or before January 5 of the immediately succeeding calendar year. GIBBON COU Oq#� rder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought.
See reverse side for additional instructions and qualifications.
Applicant(owner or contract b er-see restrictions on reverse side)s,_ ,,,,neis tc„:„.„,:_raa
Taxing District eylhumber/legal description Record number Page number
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year date of application legal or equitable owner?
I ID N-- b Q b Lam- es ❑ No
If no,what is his/her exact share of interest? S If owned with someone other than spouse,indicate with whom `t
If name on record is different than that of applicant,indicate below Is the property in question:Annually Assessed
( eal Property ❑ Annually Assessed
l� Mobile Home(IC 6-1.1-7)
Name of rtprtgagee or contract seller
Address of mortgage or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage oti k 0
xi
Address of assignee(number and street,city,state,and ZIP code) .1/4C1 ry
Does applicant own property in any If yes,what county? What Taxing District? I'- p� S ••\4 'mt of deduction
-inIndia a?y ❑Yes I to .e,\ x sr) •-0 4\�
in Indiana? .d' .
A person is not entitled to this deduction unless the person has a balance on th' y,� y.-- ' \ .•• 0 .recorded in the county
recorder's office(including any home equity line of credit that is recorded in ' S� 4°\0 u\Co - ••' 0 ,,eduction.re COUN 0 ••C� •'•v.Jx
Deduction approved in the amount of: `\••• ��
20 20 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/cont act buyer of t a aforementioned property on date application is filed.
Signature(o es full name) I Date(month,day,year)
Or 4
F 1 e address of appli t(number and street, ate,and ZIP code)
39 Do E 750 6.
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.