HomeMy WebLinkAboutMortgage_Brokaw STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township.1 VS
E FOR DEDUCTION FROM ASSESSED VALUATION
- State Form 43709(R13/1075)
Presorted by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed In person or by mail
Filing Dates: 1) Real Property Must be completed and dated in the calendar FOB Glee ''
year for which the deduction is sought.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the pope I: o ill uditor
located on or before January 5 of the immediately succeeding calendar year. Ii
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Audits of the county. J lit .i,.. •ecorder
where the property is located during the twee(12)months before March 31 of each year the deduction is sought.
See reverse side for additional instructions and qualifications.
.1111 1x'2011
Applicant(owner or contract buyer-see restrictions on reverse side
Rerlercekcy. enknl,J a-nlnmy S. Rcnkaw +A /ti e96/
Taxing District Key number/legal description Recd r number
-. 1P-- I-7--0I _4404-000., 3 —ma. GIBSON COUNTY UDITOR
Assessed value of real property as of Mortgage/Contact indebtedness
assessment date,anal year assessment date,current year unpaid as of of aap�on indebtedness unpaid as of Is the equitable the sole
e
Q(� p legal«egcdlable osseR
If ro,what is hs/her exact share of interest? i I / O) O ' oo 'Yes ❑ No
If owned with someone other than spouse,Skate with whom
.
If name on record is different than that of appfmant,indicate below:
Is the property in question:Annually Assessed
ErReal Property ❑ Annual 'Assessed
Name of Mobie Nome(IC 6-1.1-7)
ogee«mnvacr seller
(ai■ke( 1--0me r\s, Tnc .
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 city,state,and ZIP code)
Does applicant own properly in any If yes,what county? What Taxing District? Has this deduction been requested If
in Indiana? ❑Yes Lit No on property t« yes,state amount of deduction
omen 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/contract buyer of the aforementioned property on date application is filed.
Signarona name) Y %�4 ^ Date(month, y,year)I, Cuq(LL4( /6 e/X-YC LJ 7/5
7
Full resident address of apppllica number and street city,state,and
d�Z�P code) (,(�] /
. Io authorized by'duy executed Sic. , C by C 61� V i 11e 1 t �l(/S
Person 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 510,000.
RECEIPT FOR FILING STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS I
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