HomeMy WebLinkAboutMortgage_Cox (12) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
..��`- FOR DEDUCTION FROM ASSESSED VALUATION
'`' State 43709(R13 10-15)
Prescribed by Department o f Local Government Finance FILL])
INSTRUCTIONS: •
To be filed in person or by mail Form filed with:
Filing Dates' 1) Real Properly.Must be completed and dated in the calendar year for which the deduction is sought OCT 25 17
Must be filed orposbnarked with the County Auditor or County Recorder of the county where the property is County Auditor
located on or before January 5 of the immediately succeeding calendar year. n ��..4 Cou Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with The County Auditor of the h• j
where the property is located during. : . (12)months before March 31 of each year the deduction'
See reverse side for additional instructions and quer :•ons. GIBSON COUNTY A.UD!TOR
Applicant buyer- restrictions• - - side)
c p 0z. ggeld
number Page number 1.irssfsed
slue of nal property as of Mortgage/Contract indebtedness unpaie as of Mortgage I Contract indebtedness unpaid as Is the applicant the sole
assessment date,asTad year assessment date,and year date of application g� legal or equimbhe wooer?
/ , ❑ Yes 0 N
If ro,what is his/her exact share of interest? If owned with someone other than cprurcn,inQVate with whom
tl name on record is afferent than that of applicant,indicate below n property in question:Annually Assessed
AI Real Property ❑ AnnuallyAssessed
Mobile Hone(IC 6-1.1-7)
Name of mortgagee or contract seller
1 / e/o.XO
Address of mortgagee or contact seller(num-'•atreet city,sta ,and ZIP code)
Name of assig r owner r holder• ge �/ .n J/�/'J.F/1� /) 2ALA/-4 ///"y,�/I/�/J
Address of assignee bar d street city,state,and ZIP a �(�%�'//Q�}J
Does applicant won property in any If yes,what county? what Taxing District? Has this deduction be€n requested If yes,state amount of deduction
'mnindiana?? ❑Yes ❑No on 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 ot.
20 20 2( ot V / 7 - Os-co 0 20 20
Signature of County Auditor Date(month,day,year)
Drawer NO
/) 1 I/We certify under the penalty of perjury that th that the applicant is a resident of Indiana and
(112-1 owner/contract buyer of the aforementioned pr Card O.
Signature MO name) Date(month,day,year
Cbac
Full residegtadtlress of cop (number and sheet city,state,and ZIP code)
ALAI S. Whit uti Ni1� Rd. Oakland CiI-�;S )- '{1Lat )
Person authorized by duly 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)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.