HomeMy WebLinkAboutMortgage_Harpe (2) a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
L'#sss'\�g-7 FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43769(R13!10.15)
Prescribed by Department of Local Government Finance t I
I ':aI( a i
INSTRUCTIONS: i1 (,'
To be filed in person or by mail. Form filed with:
Filing Oates: 1) Real Properly.Must be completed and dated in the calendar year for which the deduction is sought 1 (�3�
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is V U Auditor
located on or before January 5 of the immediately succeeding calendar year. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the County Auditor of the county
•where the prapedy is located doing the twelve(12)months before Math 31 of each year the deduction is -. �j 4,
See reverse side for additional instructions and qualifications. GIBBON r`ou - ;'
Applicant( or mnaacr buyer- on r se side) A iJ l t OR
� / Key number! tlescripfian Record number Page number
C4 07�- ///a lea or 4,3. ga3 - cot7 /`7 11148
Assessed value of real p 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,aarent year data of application / 0b legal or equitable owner?
!�- ID Yes ❑ No
If no,what is his/her exact share of interest? If aimed with someone other than commie,indicate with whom
If name on record is different than that of applicant indicate below. Is property in question.Annually Assessed
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
•573
Address of mortgagee or contact setter(number and street city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage .
Address of assignee(number and street,city state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
otter in an? aieny ❑iana ❑Yes ❑No current ea? 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 20 20 20 20 20
Signature of County Auditor County • Date(month,day,year)
•
I 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 flied.
`T/� ,l( nam/�ee,)e( A' ^ Date(month,day,year)ent address 1
9::(owneriS
( p�AA�tv 1(nar�bra'i�c A,3f/c tA,city ,and ZIP�' u l ) 5 ? Ckl\\I V Y i
V1Cp
Person authorized by duly Power of Attorney or by IC 6-1.1-12 .7 Date(month,day,year)
Address of authorized person (number and street city state,and LP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.