HomeMy WebLinkAboutMortgage_Harker STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
L FOR DEDUCTION FROM ASSESSED VALUATION •
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- State Forth 43709(R13/10-15)
�- Prescribed by Department of Local Government Finance
INSTRUCTIONS: g
To be filed in person or by mail. () fi with:
Filing Oates 1) Real Property.Must be completed and dated in the calendar year for which the deduction is
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is L County Auditor
located on or before January 5 of the immediately succeeding calendar year. �r�iT qq nj�
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the cratyv 5 2 Ch'' County Recorder
where the property is boated during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications. d�
Applicant(awrmrwcoritract buye -see on reverse sides) fiG O
Cc nao �'11�� ) /. GIBBON COUNTY AUDITOR
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Tar n9 District Key /kglidesaiphon Record number Page number
7/ / / A6 - / 8- .3 (a - ‘40l - 000 . 63 /- 009 20/6 I/v2
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment data,current year assessment date,current year date of application / legal or equitable owner?It-O a( 00?) ❑ Yes ❑ No
If no,what is his/her exact sham of interest? If owned with someone other than Ter MP.indicate with whom
If name on record is different than that of applicant State below Is the property in question:Annually Assessed
❑Real Property ❑ AnnuaflyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller A •
Address of mortgagee or contract seller(number and/street di state.and ZIP —_ 1- /� _ __ . ___ __ _
Name of assignee or other owner or holder of mortgage ��7:g12077-/y�" c�
Address of assignee(number and street city,state,and ZIP code) D
/4)0-3-t aa- 4M 4 L /- 9 SUZETTE /'h —
Does applicant own property in anyV If yes,what county? Mat Taxing District? Has dad
other county on p ry t -1 I i .Ira
in Indiana? ❑Yes ❑No aurent year
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebwedrroaa .__
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,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!contract buyer of the rementioned property on date application is tiled.
Signature fu0 Dale(month,day,yeah ii.n
XL /Full resident of applicant(number and street city, ,and ZIP aide)
�I9I Nerr1 CamMtLL 11UP bsrsd7,Z4) q/7( 39
Person authorized by duly executed Power of Affimey or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street dry,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed S10,000.