HomeMy WebLinkAboutMortgage_Lyons . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
��,,[��[�y,1��;+� . FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
�-- Presalbed by Department of Local Government Rnance
FILE INSTRUCTIONS: File Mark
To be filed in person or by mail. Form filed with:
Filing Dates.- 1) Real Property.Must be completed and dated in the calendar year for which the ,may sought
Must be filed or postmarked with the County Audtor or County Recorder SAO a Ln Mhb e the property is A 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 Cou, ty 'acid the county
where the property is located during the twelve(12)months before March 3 f e deduction is sought
See reverse side for additional instructions and qualifications. ,.�.�au Al IDITOR
Applicant(owner or contract buyer-see restrictions on reverse side) GIBSON cOUt
i/ ¢ a robes
Tarry is4ict number!legal Record number Page number
�«�O�"- Z(-/7-J - Oki q-ay. /97- oaa I 7 IR90
Assessed value ofreal property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment dare,aurent year dare,anent year date of application legal or equitable owner?
6 cb- ❑ Yes ❑ No
If no,what is his I her exact share of interest? 1 If o.aaw'-" deli- whom
t name on record is different than that of applicant indicate below , n 5 :h an:Annually Assessed
• ' l) �J f 7 MnnueOHom Assessed
6
�J Mobile Home(IC G7.1-7)
Name of mortgagee or-. ,-ct sell-
Address of mortgagee/contract seller(number and sheet,city,state,and ZIP= /•/1, /N 9O
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other on property for
in Indiana? Yes ❑No =rent year? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
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.
Siggnature e((owwnneers lull name) Data(month,day,year)
Fop residefii address" of applicant 7
pppcant(number and street city,state,and ZIP code)
>4 4 1 0.E SocgL ,4 4:'1 S/. n/Jo" sue;//r° 11.. 9 7&20C
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. • •