HomeMy WebLinkAboutMortgage_Lutz (5) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Cou Township Year
r _r', FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
`— Presalbed by Department of Local Government Finance �� a
I .7 d -Ie'. . ,_ i
INSTRUCTIONS: _,, s ,
To be filed in person or by mail Form filed with:
Filing Oates' 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought n c�((-'
Must be Ned or postmarked with the County Auditor or County Recorder of the county where the pro/4144s 2 0 r Q[Q 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 file with the County Auditor of the -r unty
where the properly is located during the twelve(12)months before March 31 of each year the did t '(,17 •:•y j'i ill
See reverse side for additional instructions and qualifications.
Applicant(owner d see -- -on re .--side) GIBBON COUNTY AUDITOR
11 jai s % Chi-,�-
T g Key,number.„ / n number ,p7ay rum r doz_
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contact Indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application �yy� legal or equitable owner?
/3...2/ ❑ Yes El No
If m,what is his I 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 baby. Is property in question:Annually Assessed
Real Property ❑ Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller Q ad / - �x /� //
Address of mortgagee or contact seller(number and street V/('t l ststaa1.ZIP code) (� / (/`/L//l!/
Name of assignee or other owner or holder of nartgag D / •
. a�� / 9
Address of assignee(number and street city,state,a ZI e)
"‘"es applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested -If yes,state amount of deduction
on property for
-"rives ❑No current year? ❑Yes ❑No
• - -'c•fuction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
` `�S �-aw line of credit that is recorded in the county recorder's oWn9 that is the basis for the deduction. .
DI;a)),CI l NnO COUNTY AUDITOR
ocl)Card A 0 �C� 20 20 20 20
Signature of County.•.r7 County - Date(month,day,year)
I 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.
‘‘.1.
Signature(owners full name) Date(month,day,year)
4
\/ Fuent address appbcan umber and street,dly state,and ZIP code)
f` l BrajI/iV 1>✓i`re l*iuhslaciI /N 6/7635
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. .
g�-->T_._