HomeMy WebLinkAboutMortgage_Gambrel STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
• .x� County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION F I p
co) State Form 43709(R13110-15) N� B F. y
Prescribed by Department of Local Government Finance 1I1� 19i tMl
INSTRUCTIONS: File Mark
To be filed in person orbymaiL MAR 03 2017 Form filed with:
Filing Dates: 1) Real Properly Must be completed and dated in the calendar year for which the deduction is sought ,—,,C
Must be filed or postrnarked with the County Auditor or County Recorder of the cou where the property is R 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 Co.1 t'• .ni r,�r!!tr•i county
w h e r e the p r o p e r l y i s located d u r i n g the twelve(12)m o n t h s b e f o r e M a r c h 3OfB€OflC o.' •-•".i•.. k ••
See reverse side for:,ditional instructions and qualifications.
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T. :..h_ •• J/ f' ' - ;• ,._ /�9�description/a-I -3 o'i-a)0. 98)...00/-2, Record n(mb�L Pa/e/ 1 r
Assessed value of real properly as of Mortgage/(Co '.. indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of fIIs the applicant the sole
assessment date,current year assessment da'1:4:,-nt date of application legal or equitable owner?
���
El Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom '
tf name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
. ❑Real Property ❑ Annually Assessed
' Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and street city,state. LP code)
Name of assignee or other owner or holder of mortgage / J?
Address of assignee(number and street,city.state,and ZIP co 1 O O
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pia)‘el' (/J�
Does applicant own property in any If yes,what county? / t/ /Q
sled If yes,state amount d deduction
other county 1 ..
in Indiana? ❑Yes ❑No Card NO• ......• INo
A person is not entitled to this deduction unless the person - 'tedness that is recorded in the county
recorder's office(including any home equity line of credit t ___,—at is me basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 20 20
Signature of Court u ' County Date(montbd ar) //'i
1/We ''try under the penalty of perjury that the above ' information is true and correct and that the applicant is a resident of Indiana and
owner 1 Watract buyer of the afore jientioned pro3ertr on date application is filed. (synth, `g{�
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Person authorized by duly executed Power of Attorney or 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.