HomeMy WebLinkAboutMortgage_Robbins (3) StSTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
� State Form by Department par meet .r
Prescribed by Department of Local Government Finance ItlIL�f
INSTRUCTIONS: File Mark
To be filed in person or by mail. Form filed y'th:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for h3he 4&&ion is sought. ,.,._,/
Must be filed or postmarked with the County Auditor or County Reco er of the county where the property is L7 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 i with e l Auditor of the county
where the p •-rty is located during the twelve(12)months before r the deduction is sought.
See reverse side for addition: instructions and qualifications. GIBSON COUNTY AUDITOR
Applicant(owner wcon :A4/- -see td 'ons on re e)
7 ber/legal ption R numb r Page nu
i ' a I • / d;-)a-o�3o3-000 . ' S -oas /tD Iwo r
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,curr 7%J riOo date of application legal or equitable owner?
l& / ❑ 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• mortgagee-r contact seller
,, e hi •
Address of mortgagee or contract seller(number and str•et,ci ,state,and ZIP code)
N: rfn /t 8 !7‘, %13 ` ldc i7✓5-GO
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rid FICmdO(lY1 Le.deVS
_ Drawer \O.•••
ao -... .-
Do, • iat Taxing District? Has this deduction been requested If yes,state amount of deduction
oth \ 4°` on property for
in Ir current year? ❑Yes ❑No
A pc
Card N 0• -'' balance on the person's mortgage or contract indebtedness Mat is recorded in the county
recd _ _...,....luny une or 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
Signatu ofC u dit / i County Date(month,d ar)
off3—ad
I I We certify under the penalty of perjury that the above and ing 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.
ignature( r Ina Date(month,day,year)
� �
ull reside ddress of applicant(number and street,city,state,and ZIP code)
y92 W Glendale St
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 S10,000.