HomeMy WebLinkAboutMortgage_Hale (3) a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
;- Slate Form 43709(R 13/10-15)
Preso-bed by Department of Local Government Finance
INSTRUCTIONS: 7
File Mark
To be filed in person or by mail. dEdrhm�rori rs� Form filed with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the sought
Must be filed or postrnarkad with the County Auditor or County Recorder of the county where,ffig P fd is ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. M�II' Lull ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the Coy dtty7luditor of the county
where the property them the iontwelve(12)rrhonths before March 31 of each year Mededuction
See reverse side far additional instructions and qualifications.
Applicant(owner ortynpaU buyer-see=verse reverse side) V
U)(J�r\�D GIBBON COUNTY AUDITOR
T - District )Key number l legal Recatl number Page number
N. D c)-(0 - tel �a -a Do, ��c.g- aaK /7 33ro
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,arrant year assessment date,orient) year date of application legal or equ'itabl'e owner?
10 la U � ❑ Yes 0 No
If no,what is hhis xa
/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is d�erent than that of applicant,indicate belay. Is the property in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
• Mobile Home(IC 6-1.1-7)
Name of mc pa L`ortgagee or contract seller LL.� -
LEVI ill
Address of mortgagee F or contact seller(number and sheet 1 i -. -- _.
Name of assignee or other owner or holder of mortgage ) 1 -33/0
Address of assignee(number and street city,state,and ZIP
Does applicant own property in any If yes,what county? wear iw.uy Ls.—. equested If yes,slate amount of deduction
in Indiana? ❑Yes ❑No I I current 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 Cowry - Date(month,day,year)
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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.
Signature(owner's hlii - / Date(munch,day,year)
T /c.
Full resident address of applicant(number and sheet city,state,and ZIP ccood1\ -1 �[
`f' 1 w4. O ( rc SO_Anti R-J4--6h-r--c�►7 Y \cto^1Lfi°-- 'C). V G i Cl b
Person audpr• ed 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)
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The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.