HomeMy WebLinkAboutMortgage_Queen (2) �a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
' FOR DEDUCTION FROM ASSESSED VALUATION
ti '' State Fonn 43709(R13/10-15) g
Prescribed by Department of Local Government Finance n + N R J
INSTRUCTIONS: _ NflL.etl-dl8f Oc'/.
To be filed in person or by mail. Form filed with:
Filing Oates- 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought P �17
Must be filed orposbnadred with the County Auditor or County Recorder of the county where the property is S E "County Auditor
located on or before January 5 of the immediately succeeding calendar year ■ sun c ecorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the cou ' - A _e
's
the properly is located during the twelve(12)months before March 31 of each year the deduction is -. . :....,nit
See reverse side for additional instructions andquafrfications. GIBSON COUNTY AUDITOR
Appficar%vara or contract buyer-see restrictions on reverse site)—
siga,nt ht. d- j c X Qi.
T istict Key number/legal description Record number Page number
•-...04> ar� n d4 - /(. / 5 -io/-003.9782 -6A7 dD/7 / S-77
Assessed value of real property of Mortgage I Contract indebtedness unpaid as of Mort gage/Cor aact indebtedness unpaid as of Is the applicant the
assessment date,and year assessment date,current year date of application legal legal or equitable owner?
If ro,what is his 1 her exact share of interest? /� If owned with someone other oh s�O,mediate with whom ❑ Yes ❑ No
If name on record s different than that of applicant,bndiale below Is the property in question:Annually Assessed
• — ❑Real Property ❑ 1.1-7)
Name of mortgagee or contract seller 12 ,r X L
Address of mortgagee or contrail seler(number and street aly,state.and ZIP code) Q , -C L q
Name of assignee or other owner or holder of mortgage it S ' p
t n tOU. O0
Address of assignee(numbrl�rtl street dry,state.arrg.7jrr code) 11 a Do t) - ( G - cj
Does applicant in any I es,what county? What Taxing District? Has this deduction been requested I tr ya,r...- rddion
Indiana?
other ia'anna?ry Yes ❑No cement r? ❑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 recorders 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 coned and that the applicant is a resident of Indiana and
owner 1 contract buyer of the aforementioned property on date application is filed.
x Signature lull name) Date(month,day,year)
adcteA a ppGant cry,state,and LP code)
a(139 w . )01 e c ?r;4( c0+, /I) 57070
Person authorized by duly executed Power of Attorney or by IC 5-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street Sy,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.