HomeMy WebLinkAboutMortgage_Dilbeck (2) „znv STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
■il_,F�3. FOR DEDUCTION FROM ASSESSED VALUATION
ltt State Form 43709(R12/6-14) ���"""'''��� �''1
Prescribed by Department of Local Government Finance g p-{ J L �-{
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INSTRUCTIONS: File Mark
To be filed in person or by mail. n Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for whicfO&Tdeeucticall ought.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is County 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 w't e r of the county
where the property is located during the twelve(12)months before March 3 eduction is sought.
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
Applicant(owner or -r- .-restrictions ojrev- •-/side)
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Taxi g!i, dct f Key number/legal description , number Page number
1 •1I 4 ‘-/o /co -o�.sab-oa( �.ois 3c,BS-
Assessedrvalue• -i property al Mortgage/ tract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,anent yea March 1 ettiypar _ _ date of application legal or equitable owner?
�('l((//MV/�V-1 ❑ 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
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller (1 „ n
•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, r- Ldty,state,and ZIP code)
D OS�LA., \ • A',AV>eS- What Taxing District? Has this deduction been requested if yes,state amount of deduction
o AO Vt. sAjic on property for
�i� �CC� current year? ❑Yes ill No
A, as a balance on the person's mortgage or contract indebtedness that is recorded in the county
re, ot c i c i5o-?,��. si _31_ap Is t is recorded in the county recorder's office)that is the basis for the deduction.
OOO.00) COUNTY AUDITOR .
0 \S 1 2OkS - 3(DS
20 1 20 20 20 20 20 20
Signature of County ud' r 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.
i tur Owner's II name) Date(month,day,year)
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ull rest t address of applicant(number and street,city state,and ZIP code)
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IU. tWOS. Oweisi«k` (1I gib ,6
Person authorized by duly executed Power of Attomey 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. -