HomeMy WebLinkAboutMortgage_Woolems �yQ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
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%i:_'r- . - State Prescribed by D Department T T
.0 f Prescribed by Department of Local Government Finance ( �Agj �y �/'
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. APR 2 q__ th
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is '"LL77``CC unty •Auditor
located on or before January 5 of the immediately succeeding calendar year C un ecorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the courl�t/
where the property is located during the twelve(12)months before March 31 of each year the deduction is
See reverse side for additional instructions and qualifications. G I B S O N COUNTY AUDITOR
Applicant(owner or contract buyer-see restrictions on reverse side)
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Ilig 'strict Key number/legal desriiption 0 A 7 Record number Page number
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Assessed value of real 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?
r3 O// 0 0 D ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other Ulan 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 Ascacsed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contact seller --- ---- —
Address of mortgagee or contract seller(number and state,and LP e) bb tan 5/
Name of assignee or other owner or holder of mortgage 'Se-72 k y in
Addtgss of assignee(numberand street,city,state,and ZIP code) Q1HAlC.� —
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Dos applicant own property in any If yes,what county? What Taxing District? Has thi I 62 - 1 4 D g
other county on plot
in Indiana? ❑Yes ❑No current
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or wnu o,,......__.-.
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.
z.-Signature(owner's MI name) Date(month,day,year)
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I respde address of applicant(number any7sfn=,et,city state,and ZIP code) T
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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)
UT/
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 510,000.