HomeMy WebLinkAboutMortgage_Shade _P, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
,�� County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION •
State Forth t 10.15)
Prescribed by D epartment of Local Government Finance Jg L - I l
INSTRUCTIONS:
To be filed in person or by mail. Form filed with:
Fling Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is soughtl U L 1 8 2017
Must be filed or postmarked with the CourdyArrdtor or County Recorder of the county where the property is. [B County Auditor ;
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property.Must the with the County Auditor.yy1 rwr .,i ■ County Recorder
where the property is located during the twelve(12)months before March 31 of each year the dad . ""'% 1. -
See reverse side for addrtrona/instructions and qualifications. GIBSON COUNTY AUDITOR
Applicant(owner or contract buyer-see restrictions an reverse side)
or Aoa 5 OLQ
Taxag District number deaaipwn Record r
A)�eet�t.) -/,- -Ole � coa ca
S" `
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of,Fri
/Contract indebtedness unpaid as of Is the applicant the sole
assessment dale,and year �assessnent data,aa/rereIYy�e'aarr date of application legal or equitable owner?
' l I . Lo Oc62.00 ❑ Yes ❑ No
If no,what is his I her exact share of interest? If owned with sanwne other than spouse,indicate with whom
If name an rend is deferent than that of applicant,indicate below. Is the property N question:Amway Assessed
/� yf Real Property ❑ Muiva Horne 6-1.1-7)
Name of mortgagee or contract (i� t / l .
Address of nrurtyay.t or contact seller(number and stee4 city,state,iKandd ZIP code)
Name of assignee or other owner or holder of mortgage ' •
Address of assignee(numuberand street ray,state,and ZIP code) • .
Does applicant own property In any If yes,what county? - What Taxing Distil? Has this dedvdmn been requested If yes,state amount of deduction
other
lodl ? ❑Yes El No • current year? ❑Yes ❑No
A person is not eatWed 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 hone equity fine 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,fear) '
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/contract buyer of the entioned property on date application is fled.
S',. . -fie name) r ') Date(month,dal:year)
Il _ I C Nit
Ir ad ap ( and street,dy, and ZIP code)
x. ib(d% , S - ?[i�Ca snl -17&10
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet,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.