HomeMy WebLinkAboutMortgage_Baker (8) is STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou Township Year
.
FOR DEDUCTION FROM ASSESSED VALUATION
�'- State Form 43709(R73!10.15)
Presalbed by Department of Local Government Finance
I e Mn Ai D
INSTRUCTIONS:
lb be filed in person or by mail. rdilililed
Filing Dates: 1) Real Properly.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 properly iss EP County Auditor
before on or bee January 5 of the immediately succeeding calendar year. ' Z@bfinty 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 is so .
See reverse side for additional instructions and qualifications. It
Ap ownecorcontract see on reverse side) GIBSON COUNTY AUDITOR 76 )
Taxing - • �Key t legal description Record number Page number
orb -IX - 0 Co - Lida. -ooq. 3 a-6 - o)- 9 AD1 (o 3 %.3 1
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application legal or equitable owner?
aoY) 000 ❑ Yes 0 N
If no,what is his/her exact share of interest? If owned with someone other Oran spouse,indicate with whom
O name on record is different than that of applicant indicate below. Is the property in question:Annually Assessed
[g Real Property ❑ AnnuallyAssessed
- e(IC 6-1.1-7)
Name of mortgagee or contract seller
71-40- e a01 ,4 - 34y1
Address of mortgagee or contract seder(number and street city,state,and ZIP code) E C C�o\ 4-
J \J KC
Name of assignee or other owner or holder of mortgage -\--Tz. () `v Q
.yD_uy Doe . o f
Address of assignee(number and street city,state,and ZIP code) a`_ l
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 in Indiana? ❑Yes ❑No curreent yearar ❑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
Deductron approved in the amount ot.
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.
Sig re(owners tuft name) Date(month,day,year)
�ddres� _ �-IJan x///111 ., 0
/ 9 t(number and sheet al:state. ZIP' ure) /I� 6'
hsr� ,��/./5 Q
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$10,000.