HomeMy WebLinkAboutMortgage_Camden Jr STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
'I:, FOR DEDUCTION FROM ASSESSED VALUATION
_ '., State Fonn 43709(R13/10-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: �L- ^.Ir`
7b be filed in person or by mail ,,: . ::wnh:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is so L
Must be filed orposfmarked with the County Auditor or County Recorder of the county where the property is o County Auditor
located on or before January 5 of the immediately succeeding calendar year. n�[[rr 2 8 0 County Recorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of therLlbirlity
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
(owner orcontraa see o reverse tide)
*' GIBSON COUNTY AUDITOR
Taring District number/legal it
Record number Page number
'orbe12-os-loo-coo. aCo oaf �� s� 18
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpa' as of Is the applicant the sole •
assessment date,aurent year assessment date,current year date of apprmation legal or equitable owner?
I.� �D ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone otib than spouse,indicate with whom
If name on record is different than that of applicant indicate beiwr. Is the property in question:Annually Assessed
❑Real Property ❑ MnualyAssessed
• Mobile Home(IC 61.1-7)
Name of mortgagee or contract seller
0 N C
Address of mortgagee or contract seller(number and street 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)
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 awnty on property for
in Indiana? ❑Yes CI No current year? ❑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
Deduction approved in the amount of
20 20 20 20 20 20 20
Signature of County Auditor 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.
•g . r- (ow L s full name) to month.der,ye jr)
r,` era1�
F fl u= ..-�- essc.f ap..� t /... . street afy Statesand Z e) i2t27D
Person authorized by duly executed,. - of Attorney or by IC 6-1.1-12-0.7 \/W) l 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.