HomeMy WebLinkAboutMortgage_Foley (3) ^.><4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R121614)
•„e f Prescribed by Department of Local Government Finance
INSTRUCTIONS: T Fit a 1
To be filed in person or by mail. Y I . • etr;h:
Filing Oates: 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 propertlfjs 0 CO County Auditor
located on or before January 5 of the immediately succeeding calendar year. JlU1`` 4 'yO 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 jq;ought. --
See reverse side f ddtional instructions and qualifications. 14.11P Applicant(owner or tract buyer-see restrictions on reverse sid GIBBON COUNTY AUDITOR
Taxing District K er I legal descn'ptb Record number Page number
K - l — '1-3D -Doo.aosaag" 1s J9i2-
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�{lrr ear ,. date of application legal or equitable owner?
JJ11 /fib ❑ yes ❑ No
N 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
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller I
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code) •
Does applicant own property in any If yes,what county?______'What Tavinn nict,wn I.w=thre,.warunn keen requested If yes.state amount of deduction
other county
in Indiana? ❑Yes ❑No n/� Yes ID No
A person is not entitled to this deduction unless the i I I ract indebtedness that is recorded in the county
recorder's office(including any home equity line oft ,,'(t it is the basis for the deduction.
Deduction approved in the amount of: /S�a 9 G i:;
20 20 21 20 20
I I
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 I contract buyer of the aforementioned property on date application is filed.
igna ur o,null name) �` / Dale( nth, war)
u0 gents of a ri ri (Aryn6erand street,;Y te,and ZIP code) n O
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,end ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 510,000.