HomeMy WebLinkAboutMortgage_Kegg a STATEMENT OF MORTGAGE OR FOR DEDUCTION FROM ASSESSED VALUATION INDEBTEDNESS County Township Year
'' State Form 43709(R13/10.15)
Prescrbed by Department of Local Government Finance F I L B-I:J
INSTRUCTIONS:
lb be filed in person or by mail. Fonn filed with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is soug tA N .i 201 I ��
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property County Auditor
boated on or before January 5 of the immediately succeeding calendar year
2) Mobile/Manufactured Homes not assessed as Rea/Property:Must file with the County Auditor qfj a court 0 aunty Recorder
where the property is located during the twelve(12)months before March 31 of each year the ded
See reverse side for additional instructions and qualifications. G I B SO N COUNTY AUDITOR
APPbant( tT rli) F(t Tbil 0 LA1[&.e,.id t
T D'rsVic! Key number/legal description Record nu Page number
,,bl `n�/1� 3 y—�y1.1`.', OD txx�.338 ICJ`'
Assessed volt of real property as of ; Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of applicant the
assessment dare,current year nt ear date of application legal or equitable owner?
assessrrenraym,�1 y ❑ Yes ❑ No
If no,what is his/her exact sham of interest? V.41I1 O_{1 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 ❑ AnnualyAssessed •
. Mobile Home(IC 6-11-7)gbauuttk Name of mortgagee or contract seller Y
Address of mortgagee or contract seller(number and street City, te,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZI
Does apt am property in any If yes,what county; Drawer N� .201 guested If yes,state amount of deduction
other county
in Indiana?county , ❑No �{/ ❑No
A person is not entitled to this deduction unless the; Card NO. / Le debtedness that is recorded in the county
recorders office(including any home equity line of c e basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of
20 / 20 AO 20 20 20 20
Signature o� •ud',. Coun� Date(momp=aa�,7
.. / _/J
I/. e •-rtify 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 t•• tract buyer of the aft mentionedproperty on .ate application is filed.
Signatu - - s/ I n. e) / / Date(month,day,year)
Aisswia_A_7iIkeir L.ii �//
F . resident address of applicant(number and - ,st- a d LP code)
f?n 2r SA ,..ec<stv Z-v i�j-
Person authorized by duly executed Power of Attorney or by IC 8-1.1-124.7 / Date(month,day,year)
Address of authorized person (number and sheet 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.
•