HomeMy WebLinkAboutMortgage_Cook ,� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
ci. State Form 43709(R13/10-15)
— Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail. I ? 'r
Filing Dates: 1) Real Properly Must be completed and dated in the calendar year for which the deduction is sough 112
Must be filed or postmarked with the County Auditor or County Recorder of the county where the prope : Mt 'ty 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 M�l, 4 y
where the property is located during the twelve(12)months before Mardi 31 of each year the deduction is s ugh 17
See reverse side for additional instructions and qualifications.
Applicant(owner or contract restrictions on reverse side) {�
, ee Cr& GIBSO f`r�UNr Y""- =n
Taxing District mamba l Record nu UO iltenumber
&0 ... 0- ID► -�t039- COC 01 0 / 7 i6 1q
Assessed value of real property as of Mortgage 1 Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole •
assessment date,current year assessment date,current year date of lica9n legal or equitable owner?3 ap 4 SOD ❑ Yes ❑ No
If o,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 Hone(ICS-1.1-7)
Name of mortgagee or contract seller �r(/` 1 r4.et V
Address of mortgagee or contract seller(number and sheet,rx7y,state,and ZIP axle)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,dry,state,and ZIP code) -
a011- \0-- c(
Does
oles county own property in any If yes,what county? What Taxing District? I \ than
in Indiana? ❑Yes El No ill S�1C `� , CO`k -`O
A person is not entitled to this deduction unless the person has a balance on the person's 1 county
recorder's office(including any home equity line of coedit that is recorded th
ed in e county rep CI' r c_ k
COUNTY AUDITOI
Deduction approved in the amount of 2 C 1 S-O 1 J et
20 20 20 20 __
Signature of County Auditor County - Date(month,day,year) •
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 I contract buyer of the aforementioned property on date application is filed.
Signature(owner's ru e) Date(month,day,year)
.ri(�
FWKesident address of applicant(number and street city.state,and ZIP code)
Person authorized by duly executed Power of Attomey or by IC 8-11-12-0.7 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 Iwo and a half years and a fine not to exceed$10,000.