HomeMy WebLinkAboutMortgage_Coffman nSTATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
:t FOR DEDUCTION FROM ASSESSED VALUATION
' ° State Form 43709(R131 10-15)
•-• Prescribed by Department of Local Government Finance g
INSTRUCTIONS: Fire .Ka, .pi;
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 is sought r
Must be filed or postmarked with the County Auditor or County Recorder of the county where the properly is 4 County Auditor
located on or before January 5 of the immediately succeeding calendar year. H PR 1 6[1°aunty Recorder
2) Mobile I Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the properly is located during the twelve(12)months before March 31 of each year the deduction is t
See reverse side for additional instructions and qualifications.
ApprxaM(owner orcvntraq Wr see resbtbwrs on reoersryile)
Il..�.11� -seeT A-iVV l�C•) GIBSON COUNTY AUDITOR
Taxing District Key number/legal description Record/7r r Page nu
9b - oU-aco- goo-aoa r1459- ot4 a�
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 dam,comsat year assessment date,cement year date application legal or equitable owner?
� ❑ Yes ❑ No
II n no.what is his/her exact share of interest? If owned with some0 other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below. Is the property in question:Annually Assessed
❑Real Property ❑ AnnualyAssessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and street dry,state.and ZIP code)
Name of assignee or other owner or holder of mortgage
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Address of assignee(number and street dry,state, W \`\\0'-'�
c� "za5 OQO . °u
Does applicant own property in any If yes,what o P v L I Q requested If yes,state amount of deduction
in other dcamry ❑Yes El No AO\g - tea. l d� 0 N•
A person is not entitled to this deduction unless 1 t indebtedness that is reoonled in the county
recorder's office(including any home equity!ire \-).a-\' the basis for the deduction.
............r nuulTOR
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
owner!contract buyer of the aforementioned property on date application is filed.
n re(owners rug came) Date(maga year)
ull •dent ad appfrant(number and street dry,state,and ZIP code)
Person authorized by duly executed 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 S10,000.