HomeMy WebLinkAboutMortgage_Moade , , STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS (fin Township Year
L =":t FOR DEDUCTION FROM ASSESSED VALUATION
Sta}e Farm 437 Department ta15) � ,I
Pr scnbed by par of Local Government Finance ! i,!
INSTRUCTIONS:
'• 'tI",,
b be filed in person or by mad. Form Bled with
Rung Dates: 1) Real Property.Must be completed and dated In the calendar year for which the deduction Is sought. �Z 11 •
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is �U OmY Audio?
located on or before January 5 of the immediately succeeding calendar year. _--
2) Mobile/Manufactured Homes not assessed as Real Property.Must fife with the County Auditor of the county - ❑ Cou�i -. •er
Where the property is bated during the twelve(12)months before Math 31 of each year the deduction is-. .,• 4 ,n v'•,r
See reverse side for additional instnsctions and qualifications. M GIBSOM r OUNTY AUDITOR
Appian(owner or see ' ' an re site) 1 ' ` A
Taxing District aey = _r U—®�'/�/ Record P w"/m/`y�l'/y`
Assessed valued real property as of Mortgage l Contract indebtedness wpaid as of -1 Mortgage/Contract indebtedness unpaid as of I/Is the applicant the sole
assessment tae,and year assessment date,D I date of appSz Lion legal or equitable owner?
S 0 Yes 0 N
If no,what is his I her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is dillarea than that of appfcant indicate below: Is the property in question:Annually Assessed
. ❑ Real Property ❑ Almuaty Assessed
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Mobile Home(IC 6-1.1-7)
Nene of mortgagee or contract seller C 1 1 (3 j
Address of°mtyeyee a•contract seller(number and street,city,state,and ZIP rod-A
Name of assignee or other owner or holder of mortgage ' 'O/ 7
Address of assignee(number and street cry,state,and ZIP code) Drawer NO....... e/�••�//••/l/j•/• - --- -
Does applicant own property in any If yes,what county? • What TIN ..:..••••''.. s,state amount of deduction
iindia ? ❑Yes ❑No Card NO. •••
A person is not entitled to this deduction unless the person has a baler. a.,,meantedness that is recorded in the county '
recorder's office(including any home equity line of credit that is record? - _.,.,...y recorder's office)that is the basis for the deduction.
COUNTY AUDITOR " -
Dedudion approved in the amount of:
20 20 20 20 20_ 20 - ' 2(1 •
Signature of CoodyAtaltmr 'County Date(nardh,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 I of buyer of the entioned property on date application is filed.
MI Date(month,day,year)
e7. Flzd>7
Fylt ' address (n and street,city,state,and ZIP code)
I
Person authorized by duly executed Poxes of Attorney or by IC 6-1A-12-0.7 Date(month,day.year)
Address of=hatred person (number and street,cut,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed 510,000.