HomeMy WebLinkAboutMortgage_Livermore (2) ` STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
' : FOR DEDUCTION FROM ASSESSED VALUATION
.. Stale Form 43709(R13110-15)
<- Presalbed by Department of Local Government Finance 1
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INSTRUCTIONS:bed in person Ft r .4 !'
To be filed in perm or by marl. Ji - :.�v iA.-
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 property is ,,coq ty Auditor
located on or before January 5 of the immediately succeeding calendar year. FEB I L U i/n
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county County Recorder
where the property is located during the twelve(12)months before Marco 31 of each year the deduction is sour
See reverse dig: or additional instructions and quafficatlons. - L�4ryn,
Appl,nt , ifr- 9f con� `'ye re ns use side) _ GIBBON COUNTY AUDITOR
7i-/,lam r Y-�r:�� % '4-460-�; /44'1%%Q/Lc)
Taen: w �,legal
Key�y legal description Record number Pa a mbar
, � /�15/d0 do 6)07 G/ 2 I .5_.
Assessed value of real prove t(�a/ss of Mortgage 1 Contract indebtedness unpaid as of Mortgage I Contract indebtedness npaid as of Is the ap 'ram the sole
assessment date,aunxlL � / assessment date,current year date of application /1� legal or equitable owner?
currenowne/iy 000 ❑ Yes ❑ No
If no,what is his/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 below: Is the property in question:Annually Assessed
Real Property ❑ AnnuallyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
(- 0-77 it6eVie
Address of mortgagee or contract seller(nu nd s,-- ,state, ZIP code)
Name ofasslg ,e•seer ovmer, holder ol;LL,a• •ez 099 / Ce
Address ofIgn rnu •er and street city, -te,and ZIP code)
Does applicant own property in any If yes,what county? What Taring District? Has this deduction been requested If yes,state amount of deduction
in Indianna? ❑Yes ❑No aceurent year? ❑Yes El No
A person is not entitled to this deduction unless the �- m gage or contract indebtedness that is recorded in the county
pe person has a balance r rrt
recorder's office(including any home equity line of credit that is mootrled ii 1 ---" °thn basis for the deduction.
COI o VY01 L \r ^
Deduction approved in the amount of. H Ef v,r �- ---4.
20 20 20 xN V j l _ 20
ISo aa1.-is _ (I6'
Signature of County Auditor I y.year)
1 3o - 1-7
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the appticar a _._sident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signature(owners lull name) `101�-''_f� Date(month,day,year)
Fu. residen of applicant umber and sleet,city, id ZIP code)
�` 99 7 E- G ,, c r ', fit& C e 1o,, IA- (it 7 67 d
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. - - - .