HomeMy WebLinkAboutMortgage_Dike (7) sr STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
kir"= FOR DEDUCTION FROM ASSESSED VALUATION
=' State Form 43709(873110.15) �1
Prescribed by Department of Local Government Finance Y�
INSTRUCTIONS: JIfL� File Mark-
To be filed in person or by mail.
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction rQ 60g3 2p11 Form filed with:
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ND County Auditor
boated on or before January 5 of the immediately succeeding calendar year. y ai County Recorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Au i •-ji?�?' ITOR
where the properly is boated during the twelve(12)months before March 31 of each year• • .a.G4'r.t
See reverse s side for additional instrr'ucctiiooinnssoand qualificatban/ss..� n /r[�(��'' �/5) ^ GIBSON C + •
Applicant(r) or con /\ of- (R'1[/"a�"t.C.S� // ,(�-�-+�
T - istict Key number r legal description Rend number Page number
(G!/`� o?‘-n-oi - 7 015 aaa oa°�- Q01 606a
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,current year assessment date,current year date of application legal or equitable owner?
oc 5 coo ❑ yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse.indicate with whom
If name on record is different than that of applicant indicate below: IP
s the property in question:Annually Assessed
—pal'Property ❑ Annually Assessed
Mobile Bona(IC 6-1.1-7)
Name of mortgagee�otrartseller - —--
Address of mortgagee or contact seller(number and sheet,city,state,and ZIP code) —
Name of assignee or other owner or holder of mortgage
Drawer NO ....
Address of assignee(number and street,dry,state,and ZIP code) /^�
V \
Does applicant own property in any If yes,what county? What Taxing District? Ha: Ca I. \O. boil
other county on1
in Indiana? ❑Yes ❑No con
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,yea)
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.
S" e( tut name)n Date(month,day,year)
1r Il/1l/
Full resident address of ppfxant(nu sheet,city,state,and ZIP cod
- 7115-
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 t
executed Date(month,day,year)
Address of authorized person (number and street city,slate,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.