HomeMy WebLinkAboutMortgage_Bockhold (2) l : STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
t:,'- J
��;� FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13I 10-15) TT
Presorted by Department of Local Government Finance
INSTRUCTIONS:
lb be filed in person or by mail. Form filed with:
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 grope P R 4 County Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile I Manufactured Homes not assessed as Real Properly:Must file with the County Auditor of the x.l11 ,ty . j ❑, Coss Recorder
where the property is located during the twelve(12)months before Mardi 31 of each year the deduction .R�••.,r.., •1'-",,.
See reverse side for additional instructions and qualifications. G I BSO N COUNTY AUDITOR
Applicant(own contract buyer-see ections on reverse side)
a, �,
Taxing District ! tlescnptwn Rand number a number
0 —�`te1-aDlMR. 709�ad r__ yi g
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment data,anent year assessment date,current year date of application legal or equitable owner?
❑ 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 ❑ Annually Assessed
Mobile Home(IC 61.1-7)
Name of mortgagee or llllll tract eater ...e^l,i{I , /C
Address of mortgagee or contract seller(number andbtrereet,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,ant ' 1l/\} J
Does applicant own property in any If yes,what coon D r a\1'C C 110.. 1 �'
er I f sta
other county requested If yes,ate amount of deduction
in Indiana? ❑Yes ❑No I ❑No
A person is not entitled to this deduction unless if, Card NO. ...,.l..l/�1.L.1. ..... t indebtedness that is recorded in the county
recorder's office(including any home equity the c r the 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 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 t contract buyer of the aforemen' ned property on date application is filed.
nature toil name) Date(month,day,yea
Li-Lid /
address of appfian um and sheet city, d ZIP code) n Li
3D c . c�Y\\ T
Person authorized by duly executed of Attorney or by IC 1.1- 2-0.7 7� Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
The penalties for penury can include imprisonment up to two and a half years and a fine not to exceed$10,000. _ _