HomeMy WebLinkAboutMortgage_Elpers (11) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
g FOR DEDUCTION FROM ASSESSED VALUATION -
' : State Form 43709(R12/6-14)
�' ei=° Prescribed by Department of Local Government Finance Y$I
INSTRUCTIONS:
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. p,�C,
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is MAY ' ❑a it'Auditor-
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
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 so rt , ij=l i
See reverse side for additional instructions and qualifications.
GIBSON COUNTY AUDITOR
Applicant iror contract er-s sWcti r•/erse side)ei
Taxing trict / Key n ber leg/ail14esscription Record number Page nu er
i2_ i� o — / ',or 062 cbiS- / .3
Assessed value of rv. 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 /2 nn legal or equitable owner?
r &Q(/ ❑ 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 t property in question:Annually Assessed
Real Property ❑ Annually Assessed
/��111 Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller /7/ / / n S
Address of mortgagee or contract seller(number and street,city tate,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,dfj;state,and ZIP code) a �- I /�
,01999d-e
Does applicant own property in any I If yes,what county? I What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in 6,i-o.n.o. .0.1.144_ ❑Mn- - __ — current year? ❑Yes ❑No
A; 4{,Cl r7 /J 1 /� �- a balance on the person's mortgage or contract indebtedness that is recorded in the county
rec �7 l i W. recorded in the county recorder's office)that is the basis for the deduction.
DI
Drawer NO 0905 COUNTY AUDITOR
- Card NO. ' y 1 3 1 20 - 20 20 20
Si County Date(month,day,year)
I 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.
`/ Signature(owner's full name)C. \ Date(month,day,year)
/ Full resident address of applicant(number d street,city,state,and ZIP
A ao-t �. /- s-t _ cL_ JD- 4, g-k,
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 S 10,000. a, 1