HomeMy WebLinkAboutMortgage_Marvell (2) EySTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION State Fonn 43709(R13/10-15)
• Presatied by Department of Local Government Finance
INSTRUCTIONS: , :1 . a
lb be filed in person or by mail ,with:
Filing Dates: 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought nn
Must be filed orpostmarIced with the County Auditor or County Recorder of the county where the pr 3 $p�i, 71 County Auditor
located on or before January 5 of the immediately succeeding calendar year. d
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor o1 the county County Recorder
where the property is located during the twelve(12)months before March 31 of each year the..:. soughs
See reverse side for additional instructions and qualifications. • . �jrmlf
Applicant(owner w a o verses CIBSONCOUNTyAUDITOR
Taring District ��Jn� description Rewd Page number
D6-6 -,3S-3OD —0Dl..5a5-Da,� 004
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,anent year assessment date,current year date of application legal or equitable owner?
❑ Yes ❑ No
If rho,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 o contract seller s Q..C.Jt..k . A f1-i3tt
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,dry,state,and ZIP c^ •
'/^/1 /�
Does applicant own property in any If yes,what county? Drawer N O `;^O t } luested If yes,state amount of deduction
other count .
in Indiana?county ,—, ❑No ❑No
A person is not entitled to this deduction unless the pea r debtednesst that is recorded in the county
recorder's office(including any home equity line of cam 1• `�' "-•�• •• ,basis for the deduction.
Deduction approved in the amount of
20 20 20 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(owners full name) Date(month,day,year)
r�p-�`- M, Milt-��./'C�l
d resident address of applicant(number and street city,state,and ZIP code)
•
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.