HomeMy WebLinkAboutMortgage_Conklin (4) na STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County I Township Year
as : FOR DEDUCTION FROM ASSESSED VALUATION
'. S Form 43709 / 4) ���''"''"��� g �'''�
Prescribed tate by Department(R12 6-1
of Local Government Finance II
g I y d
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. MAR 18 281"
Must be(led or postmarked with the County Auditor or County Recorder of the county where the property is [j County Auditor
located on or before January 5 of the immediately succeeding calendar year. Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the c�i htv •
where the property is located during the twelve(12)months before March 31 of each year the deduction I
See reverse side for additional instructions and qualifications. G I BSO N COUNTY AUDITOR
Applica t contract buyer-see frictions on reverse std )
.axing District Key number/legal description Record number Page number
02t, 62k - 19-l8 - Aoo - 00/• ,.3)s-oa-.6 dlo ) (0 r 0 7
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,anent year March 1,current year date of,application legal or equitable owner?
d(01 / 0 0 0 11 Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone otter than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: ••-•..-.....•.I(s the property in question:Annually Assessed
OxrpJ.l u .n_raeoad
J 6-1.1-7)
1Name of mortgagee or n'uact seller 7,(/)-1-101/%—'
,,
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) /�J(•/-/1
1 Name of assignee or other owner or holder of mortgage ` o/4,7O E9
Address of assignee(number and street,city,state,and ZIP code) ••••..••..••• 111
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes No current year? ❑
El 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 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.
.gnat >(ow s fu nam / Date(month,day,year) /
rML
side t address of pp• .nt(num Yr and street,city,state,and ZIP e)
9 (5 , . . • x Y7lay8
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.