HomeMy WebLinkAboutMortgage_Green (9) a.:. STATEMENT OF MORTGAGE OR CONTRACT
VALUATION
County Township Year
t 42'u FOR DEDUCTION FROM ASSESSED VAATION State Form 43709(R13/10-75)
<L Presented by Department of Local Government Finance 77T----111 T�
INSTRUCTIONS: _ F T"'e May 1:[;)
To be filed in person or by mail 1 • ALA
Filing Dates: 1) Real Property.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 property is my Auditor
located on or before January 5 of the immediately succeeding calendar year. MAY ' 2
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county unry Recorder
where the property is located during the twelve(12)months before March 31 of each year the deduction is -.
See reverse side for additional instructions and qualifications. .`( , -Aunt".
Appfiant(cone^ rraabuyer-see :,u.asfre ) / ue ` GIBSON COUNTY AUDITOR 3
Taxing District ` �y�Jl Kwynumber/legit Recital number Page number
�6 -12-01- 204-003_1109-oaf . a O '7 a l d�8
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessmentdate,age year date of application legal or equitable owner?
If no,what is his/her exact share of interest? 1 Tit grit
If owned with someone other than ❑ Yes ❑ No
spouse.indicate with whom
If name on record is efferent than that of applicant t indicate below: - Is the property in question:Annually Assessed
❑ Real Property ❑ AnnuallyAssessed
• Mobile Home(IC 6r11-7)
Name of mortgagee or contract seller taisi Sandie
Address of mortgagee or contract seller(number and sheet,city,state,and ZIP code)
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? lAtW Taxing District? Has this deduction been requested If yes,state amount of deduction
other county , property for
in Indiana? ❑Yes ❑No _ ourrent 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
recorders office(including any home equity line of credit that is recorded in the county nacerders 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)
•
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
er f contract buyer of the aforementioned property on date application is filed.•
i ��e {grnname) q��/�,, Date(month,day,year)
l `r�l� 57a LP C7 vI �` '7O
Person authorized by duly executed Power of Attorney or by IC 6-11-12-0.7 (O! 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.