HomeMy WebLinkAboutMortgage_Nimrick aA STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
,t:_4
�;; FOR DEDUCTION FROM ASSESSED VALUATION
.%-i�=`''1.1.-4 State Form 43709(R131 10-15)
S„> Presorted by Department of Local Government Finance
INSTRUCTIONS: Fil a
lb be filed in person or by mail.
Filing D
Filing Dates: 1) Real Properly:Must be completed and dated in the calendar year for which the deduction is sou ft-
Must
be Ned or postmarked with the County Audjtor or County Recorder of the county where the property is •unty Auditor
located on or before January 5 of the immediately succeeding calendar year. (1�T unty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the cxiQ1 5 HID
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See rave •' e for additional instructions and%afdocations. //���� _
APP (� rc tWiler-see ..,,•;•, . on'everseside) �Q /09/2i(°4, r{.,•.
��fL'4 1� GIBSO7NN�r''C�o^^OUNTY AUDITOR
' o ; :?c,0 - o% 3Z = ooie Nor b& wja
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract Indebtedness unpaid as of Is the applicant the sole
assessment date,amen year assessment date,current year date of applications legal or equitable owner?
4,7 030 ❑ Yes 0 N
If no,what is his/her exact share of interest? If owned with someone other than we/reuse,indicate with whom
tf name on record is efferent than that of applicant indicate below. Is property in question:Annually Assessed
Real Property ❑ Annually Assessed
Mobile Home(IC 6-11-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seder(number t city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage /
Address of assignee(number and street city state,and ZIP code) L/
Does applicant own property in any If yes,what county? I What Taxing District? Has this deduction been requested If yes,state amount of deduction
other in county ❑Yes ❑No on current for ❑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
recorders 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
,,
l�p / �q _ 20 20
Signature of County Auditor • Date(month,day,year)
•Drawer NO•.a0/�
I/We certify under the penalty of p •''''•••••••• affect and that the applicant is a resident of Indiana and
• ner •• i not buyer of the afore' /V1 _
ic Signature(• -.v fug name) n Card �'O I o ....... Date(marts,day yam)
�\ V .A JGL 11 . a-
resident address of applicant(number and street,r.,---",',. 7•d DP code)
. :fin 115 3 I-(QAc . sra TN LAiu'11
Person authorized by duly executed Power of Attorney or by IC 6-11-12.0.7 Date(month,day,year)
Address of authorized person (number and skeet 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.
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