HomeMy WebLinkAboutMortgage_Adams (2) is STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
. �. State Faro 43709(R13/10-15)
�- Presaled by Department of Local Government Finance
INSTRUCTIONS: e
To be filed in person or by mail I , i1��;
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 CounyAuditor or County Recorder of the county where the property is �County Auditor
located on or before January 5 of the immediately succeeding calendar year. APR �Q
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county rOduMy Recorder
where the property is located during the hvehe(12)months before March 31 ofeach year the deduction is ht
See reverse side for additional instructions and qualifications.
App" nt( vn r ntrary buyer segt�-1 n nerve Side) TY A
sear/ f�tl/\ GIBBON COUNTY AUDITOR
Tamxg District Key number/legal description 3`{�� t� 4 Record'nr Tier Page number
Assessed value of real property as of Mortgage Canlracr vWebteO�unpaid V DO `� /Contract indebtedness unpaid as of Is the applicant ��
assessment date,current year assessment date,cement year data of legal or equitable owner?
❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned nth someone 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 ❑ MnuallyAssessed
Mobile Hone(IC 6-11-7)
Name of mortgagee or contract seller
,tom 4 M g.Rm
Address of mortgagee or contract seller(number and sheet city state,and ZIP code)
Harm of assignee or other owner or holder of mortgage
O. 1
A
Address of assignee(number and street city,stare,a, \\I `\0. .( -�1„ t\e kCLW 5
Doer applicant awn property in any If yes,what cot n („NI V\b-t� �� een requested If yes,state amount of deduction
in Indiana? ❑Yes ❑No $ 1 0 `_ p I Yes. ❑No
A person is not entitled to this deduction unless i
■ O 1/4..)‘-' ' tract indebtedness that is recorded in the county
recorder's office(including any home equity line a ��-3 Lt th
.A at is the basis for the deduction.
1 a\ R
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 I contract buyer of the aforementioned property on date application is filed.
�tu me Dare yO•t,� �'GV '/
ii '
address of applicant(number and street cif yy�st�atte,,and ZIP cc�od�e))
P is�d£SSnt� b.:0 44 {? 7o Date(math,daY.YaaO
Address of authorized person (number and street may,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. - - -