HomeMy WebLinkAboutMortgage_Goldman fT� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
x
., FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: I - � lam.in:lb be filed in person or by mart i filed ;
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought ���:. '.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is ■ County Auditor
bested on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county I A 6buntPrder
where the property is located dung the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for itional instructions and qualifications. 1J ,7 i
Applicant(owner or re ydal _ J l i,,,
(-Jj�),�, 'i ji �� GIBSOfN+CO`UNNT"Y^AUDITOR
Taxing District Key nu r legal desaiption Record number Page nu r�-,
a3 -&o- a00 - t 17 25-CYJ9 D/ /.�a 2
kr Assessed value of real property as of Mortgage!Contact'indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,cement year date 9f,3�p{y//Pplxation r legal or equitable owner?
If no,what is S/her exact share of interest? If owned with somboo��il ❑ Yes ❑ No
spouse,indicate with whom
If name on record S different than that of appriant,in/heats below. Is the property in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
I ^(J
Address of mortgagee or contract seller(number and sheet city,slate,and ZIP code)
Name of assignee or other owner or holder of mortgage _ _ _
Address of assignee(number and sheet city,state,and ZIP code)
-3-(,��(� - ` (.-11-1
� �\
Does applicant own property in any If yes,what county? Mat ` �� `-'O\G�C--ti ��
other county (� yes,state amount of deduction
in Indiana? ❑Yes ❑No , 5/.3 p �p •
A person is not entitled to this deduction unless the person has a b. �, J that is recorded in the county
recorder's office(including any home equity line of credit that is sec 1 a S x -S a, o o 'ie deduction.
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 correct and that the applicant is a resident of Indiana and
er/contract buyer of the afore boned p on date application is filed.
S' nature nets ante) Date(montittay,yea+)
ad of umber and city,state,and ZIP code) �_ N
SO ire __
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sweet.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.